Breast Hypertrophy, Reduction Mammaplasty, and Body Image

Breast Hypertrophy, Reduction Mammaplasty, and Body Image Abstract Background Body image dissatisfaction is one of the major factors that motivate patients to undergo plastic surgery. However, few studies have associated body satisfaction with reduction mammaplasty. Objectives The aim of this study was to evaluate the impact of breast hypertrophy and reduction mammaplasty on body image. Methods Breast hypertrophy patients, with reduction mammaplasty already scheduled between June 2013 and December 2015 (mammaplasty group, MG), were prospectively evaluated through the body dysmorphic disorder examination (BDDE), body investment scale (BIS), and breast evaluation questionnaire (BEQ55) tools. Women with normal-sized breasts were also evaluated as study controls (normal-sized breast group, NSBG). All the participants were interviewed at the initial assessment and after six months. Data were analyzed before and after six months. Results Each group consisted of 103 women. The MG group had a significant improvement in BDDE, BIS, and BEQ55 scores six months postoperatively (P ≤ 0.001 for the three instruments), whereas the NSBG group showed no alteration in results over time (P = 0.876; P = 0.442; and P = 0.184, respectively). In the intergroup comparison it was observed that the MG group began to invest more in the body, similarly to the NSBG group, and surpassed the level of satisfaction and body image that the women of the NSBG group had after the surgery. Conclusions Reduction mammaplasty promoted improvement in body image of women with breast hypertrophy. Level of Evidence: 2 The wish to change breast size is a complex and multifactorial one; variables such as beauty ideal, self-confidence, self-esteem, and body image have led women of all age groups to seek plastic surgery.1-6 Body image is the representation of one’s physical appearance, the result of a combination of perceptual-neural processes, environmental, social, and psychological factors. Its is expressed through the degree of care and satisfaction with one’s body.6 Breast hypertrophy is characterized by enlarged breasts, disproportionate to the woman’s biotype. The body imbalance caused by the hypertrophy leads to physical dysfunctions, psychological disorders, and a sense of social inadequacy.7-12 Several studies have shown that breast hypertrophy leads to postural changes, shoulder and spinal pain, and functional limitations, which at more advanced degrees can impair even the activities of daily living.7-9 Excess volume and skin flaccidity limit physical activity and reduce women’s ability to work, as well as their productivity.12-14 Breast hypertrophy can also interfere with women’s affective and social relations by triggering feelings of insecurity regarding their own bodies, expressed as behaviors of avoidance of outdoor activities, or in public and social settings and situations of intimacy. This dynamic generates feelings of low self-esteem and anxiety, which can lead to depression. Women with breast hypertrophy report the difficulty of finding clothes that fit the size of their breasts and claim that they often avoid social situations because they feel inadequate.5,7,10,11,15,16 Therefore, excess breast volume may be associated with morbidity levels that go beyond a simple esthetic alteration and require effective treatment.13,17,18 Reduction mammaplasty aims at decreasing breast size, and restoring the symmetry of the female chest dimensions. With advances in surgical techniques and increasingly positive results, plastic surgery is now considered a means of transforming one’s external appearance and a resource capable of improving dissatisfaction with body image. Thus, it is believed that reduction mammaplasty can bring significant benefits to body image and emotional health.6,16,19 Despite several studies on the positive effects of reduction mammaplasty on the physical, psychological, and social aspects,8-12,20 few studies have investigated the effects of breast hypertrophy and reduction mammaplasty on body image.21-23 Thus, the aim of this study was to evaluate the impact of breast hypertrophy and reduction mammaplasty on body image. METHODS This was an observational study carried out between June 2013 and June 2016, involving 206 women, 103 with normal-sized breasts (normal-sized breast group - NSBG) and 103 with breast hypertrophy with scheduled reduction mammaplasty (mammaplasty group - MG). The project was approved by the Ethics Committees of Universidade Federal de São Paulo (CAAE: 30223214.2.0000.5505, Opinion n. 639.052/2014) and of Universidade do Vale do Sapucaí (CAAE: 15167713.9.0000.5102 Opinion n. 303.366/2013). The MG group was a convenience sample, consisting of all patients scheduled for reduction mammaplasty at the plastic surgery service funded by the Brazilian Public Health System (SUS) of a Brazilian university hospital. The women from the NSBG group were selected from the Gynecology - Family Planning outpatient clinics of the same hospital and during the same evaluation period as the MG group. Women between 18 and 55 years of age and body mass index (BMI) < 30 kg/m2, with breast hypertrophy according to the criterion of Sacchini et al,24 who met the eligibility criteria and had already had the operation scheduled from June 2013 to December 2015 were included in the study. The criterion of Sacchini et al24 considers the mean measurements of the distance between the mammary papilla and the inframammary fold and between the nipple and the lateral border of the sternum. A mean value <9 cm indicates small breasts, between 9 and 11 cm, breasts of normal volume and >11 cm large breasts, with hypertrophy. The patients were evaluated after the previously scheduled surgery to avoid the bias of overestimating breast alteration in preoperative evaluations aiming to obtain free surgery through the public health system. For inclusion in the NSBG group, the women should have breasts considered of normal size according to the same index (mean between 9 and 11 cm). Normal-sized breast refers to a medium-sized breast, proportional to the woman’s biotype.24 To be included in this group women should not have undergone any previous surgical procedure on the breasts, and not have the wish to apply for plastic surgery. The exclusion criteria for both groups were age <18 or >55 years, BMI >30 kg/m2, pregnancy, childbirth or breastfeeding within one year, menopause, current or past history of psychiatric treatment, uncontrolled acute or systemic diseases, breast disease diagnosed or under investigation, or prior breast surgeries. Prior to data collection, all volunteers were informed about the study objectives and ethical aspects, ensuring their anonymity, confidentiality of the received information, and the freedom to withdraw their participation at any time during the study. All those who agreed to participate signed the Free and Informed Consent form. Firstly, a physical examination was performed to assess BMI and breast size.25,26 Next, the participants’ sociodemographic, economic, and clinical data were collected. Finally, three body image assessment tools that have been validated for use in Brazil, were applied through an interview guided by the researchers. The tools body dysmorphic disorder examination (BDDE),27–29 body investment scale (BIS),30,31 and breast evaluation questionnaire (BEQ 55)32 were used. The BDDE investigates negative aspects of body image, such as concern over and excessive importance assigned to one’s physical appearance, negative self-assessment, shame, embarrassment and avoidance behaviors in public and social situations, or situations of physical contact, use of camouflage strategies and body-checking behaviors.27-29 The tool was culturally validated to be used in interviews27 and is also capable of detecting symptoms of body dysmorphic disorder (BDD).18,28,29,33 The presence of BDD symptoms are classified as mild to moderate and severe according to the studies by de Brito et al34 and Félix et al.35 The BIS assesses the emotional investment in one’s body. This scale consists of 20 items, which evaluate factors such as body image, body care, and body touch. A high score indicates positive feelings about one’s body.30,31 The breast evaluation questionnaire (BEQ 55) consists of 55 items that evaluate the satisfaction with the size, shape, and firmness of one’s breasts, in relation to the sexual, social, or professional aspects, as well as the degree of comfort with one’s general appearance, breast appearance when covered by clothes, in a bathing suit, and naked, when alone or in the presence of others. It also assesses the importance of breast size to oneself and to other people in one’s relationships. The higher the score obtained in this questionnaire, the greater the satisfaction with one’s breasts. The BEQ 55 was culturally validated for Brazil among the plastic surgery population.32 In the MG group, the evaluations were carried out at the preoperative appointment at the outpatient clinic at least two weeks before the surgery (to prevent preoperative anxiety and nervousness from influencing responses) and at the six-month postoperative return. In the NSBG group, the interview was performed during the appointment at the outpatient clinic after physical evaluation to include the participants in the study and six months later, by scheduled appointment. All women, from both groups, were reminded of their sixth month return visit by telephone on the week of the appointment. The patients in the MG group were operated on by the same team of surgeons. The surgical technique used was a standardized and conventional one, with the breast reduction procedure being performed with a resulting inverted “T” scar and flap with superomedial pedicle for the elevation of the areola-papillary complex.9,22,36 Statistical Analysis The SPSS program (Statistical Package for Social Sciences, Inc., Chicago, IL), version 19.0, was used for the statistical analyses. Quantitative data were described as means and standard deviations. For the inferential statistics, the chi-square test was used to compare the groups regarding the socioeconomic profile, the t test for comparison of ages and BMI, the paired t test was used to analyze breast size, and analysis of variance (ANOVA) with repeated measurements was used to analyze the scores of body image questionnaires. The obtained scores were compared between the MG and NSBG groups (intergroup comparison) and within the same group (intragroup comparison) over the six-month period. The means were adjusted statistically by mixed-effect models to consider the observed sociodemographic differences. The level of significance used for all analyses was set at 5%. RESULTS There were no losses or exclusions in either of the groups, and all 206 volunteers (103 NSBG women and 103 MG patients) completed the follow up. The participants’ ages ranged from 18 to 55 years in both groups (mean, 32.5 years [NSBG] and 33.7 years [MG]). Table 1 presents the sociodemographic characteristics of women in both groups. Table 1. Physical and Sociodemographic Characteristics of the Assessed Groups   Group  P-value  Normal-sized breasts (n = 103)   Mammaplasty (n = 103)   Age (years)      t test   Mean ± SD  32.50 ± 11.35  33.73 ± 11.27  0.435   Range  18 - 55  18 - 55  —  Schooling level, n (%)      chi-square   Elementary school  7 (6.8%)  25 (24.3%)  —   High school  46 (44.7%)  52 (50.5%)  <0.001*   College/university  29 (28.2%)  18 (17.5%)  —   Postgraduate  21 (20.4%)  8 (7.8%)  —  Marital status, n (%)      chi-square   Single  63 (61.2%)  40 (38.8%)  —   Married  35 (34%)  51 (49.5%)  —   Divorced  4 (3.9%)  8 (7.8%)  <0.001*   Widowed  1 (1%)  4 (3.9%)  —  Children, n (%)      chi-square   Yes  41 (39.8%)  66 (64.1%)  <0.001*   No  62 (60.2%)  37 (35.9%)  —  Sacchini Index (cm)      Paired t test   Mean ± SD  9.95 ± 0.90  14.46 ± 1.77  <0.001*   Range  7.50 - 10.75  11.50 - 19.50  —  Resected weight (g)   Mean ± SD  N/A  732.05 ± 362.01  —   Range  N/A  300 - 2700  —    Group  P-value  Normal-sized breasts (n = 103)   Mammaplasty (n = 103)   Age (years)      t test   Mean ± SD  32.50 ± 11.35  33.73 ± 11.27  0.435   Range  18 - 55  18 - 55  —  Schooling level, n (%)      chi-square   Elementary school  7 (6.8%)  25 (24.3%)  —   High school  46 (44.7%)  52 (50.5%)  <0.001*   College/university  29 (28.2%)  18 (17.5%)  —   Postgraduate  21 (20.4%)  8 (7.8%)  —  Marital status, n (%)      chi-square   Single  63 (61.2%)  40 (38.8%)  —   Married  35 (34%)  51 (49.5%)  —   Divorced  4 (3.9%)  8 (7.8%)  <0.001*   Widowed  1 (1%)  4 (3.9%)  —  Children, n (%)      chi-square   Yes  41 (39.8%)  66 (64.1%)  <0.001*   No  62 (60.2%)  37 (35.9%)  —  Sacchini Index (cm)      Paired t test   Mean ± SD  9.95 ± 0.90  14.46 ± 1.77  <0.001*   Range  7.50 - 10.75  11.50 - 19.50  —  Resected weight (g)   Mean ± SD  N/A  732.05 ± 362.01  —   Range  N/A  300 - 2700  —  N/A, not applicable; SD, standard deviation. *P ≤ 0.05. View Large Table 1. Physical and Sociodemographic Characteristics of the Assessed Groups   Group  P-value  Normal-sized breasts (n = 103)   Mammaplasty (n = 103)   Age (years)      t test   Mean ± SD  32.50 ± 11.35  33.73 ± 11.27  0.435   Range  18 - 55  18 - 55  —  Schooling level, n (%)      chi-square   Elementary school  7 (6.8%)  25 (24.3%)  —   High school  46 (44.7%)  52 (50.5%)  <0.001*   College/university  29 (28.2%)  18 (17.5%)  —   Postgraduate  21 (20.4%)  8 (7.8%)  —  Marital status, n (%)      chi-square   Single  63 (61.2%)  40 (38.8%)  —   Married  35 (34%)  51 (49.5%)  —   Divorced  4 (3.9%)  8 (7.8%)  <0.001*   Widowed  1 (1%)  4 (3.9%)  —  Children, n (%)      chi-square   Yes  41 (39.8%)  66 (64.1%)  <0.001*   No  62 (60.2%)  37 (35.9%)  —  Sacchini Index (cm)      Paired t test   Mean ± SD  9.95 ± 0.90  14.46 ± 1.77  <0.001*   Range  7.50 - 10.75  11.50 - 19.50  —  Resected weight (g)   Mean ± SD  N/A  732.05 ± 362.01  —   Range  N/A  300 - 2700  —    Group  P-value  Normal-sized breasts (n = 103)   Mammaplasty (n = 103)   Age (years)      t test   Mean ± SD  32.50 ± 11.35  33.73 ± 11.27  0.435   Range  18 - 55  18 - 55  —  Schooling level, n (%)      chi-square   Elementary school  7 (6.8%)  25 (24.3%)  —   High school  46 (44.7%)  52 (50.5%)  <0.001*   College/university  29 (28.2%)  18 (17.5%)  —   Postgraduate  21 (20.4%)  8 (7.8%)  —  Marital status, n (%)      chi-square   Single  63 (61.2%)  40 (38.8%)  —   Married  35 (34%)  51 (49.5%)  —   Divorced  4 (3.9%)  8 (7.8%)  <0.001*   Widowed  1 (1%)  4 (3.9%)  —  Children, n (%)      chi-square   Yes  41 (39.8%)  66 (64.1%)  <0.001*   No  62 (60.2%)  37 (35.9%)  —  Sacchini Index (cm)      Paired t test   Mean ± SD  9.95 ± 0.90  14.46 ± 1.77  <0.001*   Range  7.50 - 10.75  11.50 - 19.50  —  Resected weight (g)   Mean ± SD  N/A  732.05 ± 362.01  —   Range  N/A  300 - 2700  —  N/A, not applicable; SD, standard deviation. *P ≤ 0.05. View Large Only two (1.94%) of the 103 patients submitted to the mammaplasty had postoperative complications. Both had a small surgical wound dehiscence, which was resolved with dressings without the need for any complementary surgical procedure. In both cases, the complication was completely resolved at the six-month assessment. Table 2 describes the results of the comparison of intra- and intergroup BMI before and after six months, with means adjusted for the differences of the groups in relation to age, marital status, schooling, and children. Patients in the MG group had a higher BMI than those in the NSBG group at the first evaluation (P < 0.001) and showed weight gain after the surgery (P = 0.016) (Table 2). Table 2. BMI Comparison Over Time in the NSBG and MG Groups Variable/assessment moment   Group   Intergroup comparisons (ANOVA)   Normal-sized breasts (n = 103)   Mammaplasty (n = 103)   BMI (kg/m2)   Before  22.84 ± 0.33  24.61 ± 0.26  <0.001*   Range  16.90 - 28.12  20.43 - 28.80  —   After  22.95 ± 0.40  25.18 ± 0.31  <0.001*   Range  17.24 - 29.72  20.14 - 34.55  —  Intragroup comparisons (ANOVA)  0.699  0.016*  —  Variable/assessment moment   Group   Intergroup comparisons (ANOVA)   Normal-sized breasts (n = 103)   Mammaplasty (n = 103)   BMI (kg/m2)   Before  22.84 ± 0.33  24.61 ± 0.26  <0.001*   Range  16.90 - 28.12  20.43 - 28.80  —   After  22.95 ± 0.40  25.18 ± 0.31  <0.001*   Range  17.24 - 29.72  20.14 - 34.55  —  Intragroup comparisons (ANOVA)  0.699  0.016*  —  SE, standard error. # Adjusted for age, marital status, level of schooling, and children. * P < 0.05. View Large Table 2. BMI Comparison Over Time in the NSBG and MG Groups Variable/assessment moment   Group   Intergroup comparisons (ANOVA)   Normal-sized breasts (n = 103)   Mammaplasty (n = 103)   BMI (kg/m2)   Before  22.84 ± 0.33  24.61 ± 0.26  <0.001*   Range  16.90 - 28.12  20.43 - 28.80  —   After  22.95 ± 0.40  25.18 ± 0.31  <0.001*   Range  17.24 - 29.72  20.14 - 34.55  —  Intragroup comparisons (ANOVA)  0.699  0.016*  —  Variable/assessment moment   Group   Intergroup comparisons (ANOVA)   Normal-sized breasts (n = 103)   Mammaplasty (n = 103)   BMI (kg/m2)   Before  22.84 ± 0.33  24.61 ± 0.26  <0.001*   Range  16.90 - 28.12  20.43 - 28.80  —   After  22.95 ± 0.40  25.18 ± 0.31  <0.001*   Range  17.24 - 29.72  20.14 - 34.55  —  Intragroup comparisons (ANOVA)  0.699  0.016*  —  SE, standard error. # Adjusted for age, marital status, level of schooling, and children. * P < 0.05. View Large Regarding body image assessment, Table 3 shows the results obtained for the BDDE, BIS, and BEQ55 questionnaire comparisons, with means adjusted for the differences in the groups regarding age, marital status, schooling, and children. In the intergroup comparisons, significant differences were observed between the NSBG and the MG groups for BDDE and BEQ55 scores, both at the initial assessment and after 6 months (P < 0.001 for all the comparisons) and for the BIS scores at the initial assessment only (P < 0.001). In the intragroup comparison, no significant difference was observed between the initial evaluation and after 6 months in the NSBG group, for any of the applied tools. But the MG group showed improvement at the 6-month postoperative period (P < 0.001 for the three questionnaires) (Table 3). Table 3. Comparison Within and Between Groups of the Scores of the BDDE, BIS, and BEQ Questionnaires* Scores/evaluation period   Group   Intergroup comparison (ANOVA)   Normal-sized breasts (n = 103)   Mammaplasty (n = 103)   BDDE   Before   Mean ± SE  37.43 ± 3.77  87.04 ± 2.92  <0.001*   Range  32.12 - 41.40  81.61 - 90.89  —   After   Mean ± SE  37.99 ± 2.08  24.13 ± 1.61*  <0.001*   Range  33.59 - 38.66  20.35 - 25.42  —   Intragroup comparison (ANOVA)  0.876  <0.001*  —  BIS   Before   Mean ± SE  82.99 ± 1.21  71.35 ± 0,94  <0.001*   Range  81.52 - 84.45  70.32 - 73.26  —   After   Mean ± SE  81.94 ± 1.00  83.71 ± 0.77*  0.157   Range  80.39 - 82.94  82.99 - 85.54  —   Intragroup comparison (ANOVA)  0.442  <0.001*  —  BEQ   Before   Mean ± SE  197.75 ± 4.57  114.93 ± 3.53  <0.001   Range  191.64 - 202.47  109.30 - 120.13  —   After   Mean ± SE  203.82 ± 4.40  230.68 ± 3.41*  <0.001*   Range  199.39 - 209.98  226.95 - 237.54  —   Intragroup comparison (ANOVA)  0.184  <0.001*  —  Scores/evaluation period   Group   Intergroup comparison (ANOVA)   Normal-sized breasts (n = 103)   Mammaplasty (n = 103)   BDDE   Before   Mean ± SE  37.43 ± 3.77  87.04 ± 2.92  <0.001*   Range  32.12 - 41.40  81.61 - 90.89  —   After   Mean ± SE  37.99 ± 2.08  24.13 ± 1.61*  <0.001*   Range  33.59 - 38.66  20.35 - 25.42  —   Intragroup comparison (ANOVA)  0.876  <0.001*  —  BIS   Before   Mean ± SE  82.99 ± 1.21  71.35 ± 0,94  <0.001*   Range  81.52 - 84.45  70.32 - 73.26  —   After   Mean ± SE  81.94 ± 1.00  83.71 ± 0.77*  0.157   Range  80.39 - 82.94  82.99 - 85.54  —   Intragroup comparison (ANOVA)  0.442  <0.001*  —  BEQ   Before   Mean ± SE  197.75 ± 4.57  114.93 ± 3.53  <0.001   Range  191.64 - 202.47  109.30 - 120.13  —   After   Mean ± SE  203.82 ± 4.40  230.68 ± 3.41*  <0.001*   Range  199.39 - 209.98  226.95 - 237.54  —   Intragroup comparison (ANOVA)  0.184  <0.001*  —  P obtained from repeated measures ANOVA. ANOVA, analysis of variance; BDDE, body dysmorphic disorder examination; BEQ, breast evaluation questionnaire; BIS, body investment scale; SE, standard error. * Values in mean ± standard error, adjusted for age, marital status, education, and motherhood. View Large Table 3. Comparison Within and Between Groups of the Scores of the BDDE, BIS, and BEQ Questionnaires* Scores/evaluation period   Group   Intergroup comparison (ANOVA)   Normal-sized breasts (n = 103)   Mammaplasty (n = 103)   BDDE   Before   Mean ± SE  37.43 ± 3.77  87.04 ± 2.92  <0.001*   Range  32.12 - 41.40  81.61 - 90.89  —   After   Mean ± SE  37.99 ± 2.08  24.13 ± 1.61*  <0.001*   Range  33.59 - 38.66  20.35 - 25.42  —   Intragroup comparison (ANOVA)  0.876  <0.001*  —  BIS   Before   Mean ± SE  82.99 ± 1.21  71.35 ± 0,94  <0.001*   Range  81.52 - 84.45  70.32 - 73.26  —   After   Mean ± SE  81.94 ± 1.00  83.71 ± 0.77*  0.157   Range  80.39 - 82.94  82.99 - 85.54  —   Intragroup comparison (ANOVA)  0.442  <0.001*  —  BEQ   Before   Mean ± SE  197.75 ± 4.57  114.93 ± 3.53  <0.001   Range  191.64 - 202.47  109.30 - 120.13  —   After   Mean ± SE  203.82 ± 4.40  230.68 ± 3.41*  <0.001*   Range  199.39 - 209.98  226.95 - 237.54  —   Intragroup comparison (ANOVA)  0.184  <0.001*  —  Scores/evaluation period   Group   Intergroup comparison (ANOVA)   Normal-sized breasts (n = 103)   Mammaplasty (n = 103)   BDDE   Before   Mean ± SE  37.43 ± 3.77  87.04 ± 2.92  <0.001*   Range  32.12 - 41.40  81.61 - 90.89  —   After   Mean ± SE  37.99 ± 2.08  24.13 ± 1.61*  <0.001*   Range  33.59 - 38.66  20.35 - 25.42  —   Intragroup comparison (ANOVA)  0.876  <0.001*  —  BIS   Before   Mean ± SE  82.99 ± 1.21  71.35 ± 0,94  <0.001*   Range  81.52 - 84.45  70.32 - 73.26  —   After   Mean ± SE  81.94 ± 1.00  83.71 ± 0.77*  0.157   Range  80.39 - 82.94  82.99 - 85.54  —   Intragroup comparison (ANOVA)  0.442  <0.001*  —  BEQ   Before   Mean ± SE  197.75 ± 4.57  114.93 ± 3.53  <0.001   Range  191.64 - 202.47  109.30 - 120.13  —   After   Mean ± SE  203.82 ± 4.40  230.68 ± 3.41*  <0.001*   Range  199.39 - 209.98  226.95 - 237.54  —   Intragroup comparison (ANOVA)  0.184  <0.001*  —  P obtained from repeated measures ANOVA. ANOVA, analysis of variance; BDDE, body dysmorphic disorder examination; BEQ, breast evaluation questionnaire; BIS, body investment scale; SE, standard error. * Values in mean ± standard error, adjusted for age, marital status, education, and motherhood. View Large Table 4 refers to the BDDE assessment in relation to negative body image symptoms. Table 4. Severity of Negative Body Image Symptoms in the NSBG and MG Groups Patients, n (%)  MG Preoperative   MG 6 months postoperative   NSBG 1st interview   NSBG 2nd interview   No symptoms  56 (54.36%)  103 (100%)  102 (99.02%)  103 (100%)  Mild to moderate  37 (35.92%)  0  0  0  Severe  10 (9.70%)  0  1 (0.97%)  0  Patients, n (%)  MG Preoperative   MG 6 months postoperative   NSBG 1st interview   NSBG 2nd interview   No symptoms  56 (54.36%)  103 (100%)  102 (99.02%)  103 (100%)  Mild to moderate  37 (35.92%)  0  0  0  Severe  10 (9.70%)  0  1 (0.97%)  0  View Large Table 4. Severity of Negative Body Image Symptoms in the NSBG and MG Groups Patients, n (%)  MG Preoperative   MG 6 months postoperative   NSBG 1st interview   NSBG 2nd interview   No symptoms  56 (54.36%)  103 (100%)  102 (99.02%)  103 (100%)  Mild to moderate  37 (35.92%)  0  0  0  Severe  10 (9.70%)  0  1 (0.97%)  0  Patients, n (%)  MG Preoperative   MG 6 months postoperative   NSBG 1st interview   NSBG 2nd interview   No symptoms  56 (54.36%)  103 (100%)  102 (99.02%)  103 (100%)  Mild to moderate  37 (35.92%)  0  0  0  Severe  10 (9.70%)  0  1 (0.97%)  0  View Large DISCUSSION The results showed improvement in the different body image aspects assessed in women who underwent reduction mammaplasty. The normal-sized breast group (NSBG) showed more positive feelings in the first interview than the women who underwent reduction mammaplasty (MG). However, after the intervention, the MG patients were so satisfied with the surgical intervention outcome that they were as satisfied as or even more satisfied than the women in the NSBG group, as demonstrated by the scores of BEQ55. The choice of a group of women with normal-sized breasts and no surgical interventions aimed to compare the MG group with a representative sample of the female population without alterations in breast volume and evaluate whether body image and the satisfaction of the women with breast hypertrophy would reach a similar level after the intervention to that observed in the group of women with normal-sized breasts. The present study did not include women with BMI above 30 kg/m2, which characterizes obesity, in either group.25 As obesity can influence body image, it was decided not to include obese women so that any changes in body image could be attributed to breast size, not obesity. We also did not include women with a history of psychiatric treatment, because the aim of the study was to evaluate women with similar characteristics that differed regarding breast size. Mental status, although compensated by treatment, could influence the responses to the questionnaires. If the patients were undergoing psychiatric treatment, symptom improvement could be attributable to the therapy or medication and not to the surgical correction of the breast hypertrophy. The NSBG group showed more positive symptoms in relation to body image, higher level of satisfaction with the body and breasts, and similar results regarding emotional investment in the body. It is noteworthy that the NSBG group volunteers, as expected, maintained their scores for the three questionnaires at the second evaluation demonstrating that this group did not change over time. On the other hand, the MG group, which initially disclosed dissatisfaction with body image, not only improved after surgery, but showed more positive feelings about the body when compared to the NSBG group. Previous studies that used other tools to assess body image,16,37,38 as well as investigations that used the BDDE to assess the effects of breast hypertrophy and reduction mammaplasty on body image,22-24 agreed with the results obtained in this study. All of them observed that women with hypertrophic breasts had a negative body image, were dissatisfied with their appearance, were insecure, were ashamed to expose their bodies, and showed social problems due to the condition. They also described that the reduction mammaplasty resulted in greater satisfaction with breast shape, size, and symmetry. According to the authors, the patients reported feeling more feminine, attractive, confident, and less inhibited in sexual and social relationships. It was observed that the new breast became, over time, integrated into the body image and the women started to show greater satisfaction with their bodies as a whole. These results show that the positive rearrangement of the body image was not restricted to the breasts alone, but resulted in an overall feeling of well-being in relation to the body.16,22,23,37,38 The six-month reevaluation period was defined in this study, as this is the mean time for complete healing. Moreover, a reassessment after this period was described as an adequate period of time for the patient to fully incorporate the new breast size into her perception.9,15,23,37,38 Although some studies suggest that body image improvement occurs as early as after the third month of the intervention, the mammaplasty benefits were observed in both the short- and long-term assessments, showing that the positive change is almost immediately observed and remains over time.15,21-23,38 Several studies15,21-23 have suggested an assessment for longer and more frequent periods to observe patient behavior, as well as body perception and image readjustment that occurs after the surgery. The NSBG group showed positive scores for body image at the first interview, which persisted at the second evaluation, showing that the degree of satisfaction with the body was maintained throughout the six-month period. This fact was confirmed in these patients, whose breasts were within the normal anatomical limits, since they did not manifest the desire to undergo plastic surgery. The studies by Kerrigan et al39 and Collins et al40 also compared the body image of women submitted to mammaplasty with those with normal-sized breasts. Both studies observed that women with normal-sized breasts evaluated their appearance more positively when compared to those with breast hypertrophy. However, none of these studies carried out a second interview after a period of time or investigated body dysmorphic disorder symptoms in this specific population. The age of the study population ranged from 18 to 55 years. This variation was established with the purpose of assessing women who were living the same period of life (ie, adulthood). As each age category has specific body image characteristics, women older than 55 years who were likely to be approaching or were already going through menopause were excluded, as well as women under the age of 18, who were still undergoing the body transformations of adolescence.41 The patients showed significant variation in resected tissue weight. Studies such as those by Collins et al,40 Spector et al,42 Saarieniemi et al,43 and Gonzalez et al44 observed that the amount of resected tissue is not a main factor influencing body image. These studies40,42-44 indicated benefits such as symptom relief and patient well-being even after small reductions.2,3,20 It was observed that the MG patients had a higher BMI than those in NSBG group at the first evaluation and showed weight gain after the surgery. Other authors also observed weight excess in patients with breast hypertrophy and postintervention maintenance or gain of measurements.9,21,44 In these studies, the weight excess was justified due to the existence of inadequate eating habits and sedentary lifestyle, which were maintained after the intervention.45,46 However, it is worth mentioning that these same studies stated that patients with high BMI have benefits in relation to body satisfaction after the surgery, emphasizing that the problems related to breast hypertrophy are comprised of a combination of factors and that the criteria leading to a positive body image are very subjective. Thus, excess of weight, when present, might not prevent the improvement with body satisfaction and gratification.9,21,44 The groups differed regarding level of schooling, marital status, and motherhood. A limitation of the present study was that the researchers had difficulty controlling the sociodemographic profile in the groups. Although intervals for age and body mass index were defined, the criteria for eligibility included breast size (normal volume and hypertrophy) and absence of previous surgical interventions in the breasts, with social status or other demographic variables not being considered for the selection. Studies in adults that investigate the influence of variables such as level of schooling, income, marital status, and motherhood on body image are rare in the literature. These studies are not clear regarding the influence of these variables on body image, or declared there was no correlation.35,47 However, to minimize biases in the present study due to the identified differences, a statistical mechanism, the mixed-effects model, was used to neutralize the contrasts. A high prevalence of negative body image symptoms, which characterized body dysmorphic disorder (BDD), was observed in patients with breast hypertrophy submitted to mammaplasty.6 Metcalfe et al48 indicated the presence of BDD in patients submitted to reconstructive breast surgery. Although the population of the present study did not have the degree of deformity caused by mastectomy, such as that studied by Metcalfe et al,48 nevertheless, breast hypertrophy characterizes a clearly observable deformity and the authors were careful to assess the symptoms for BDD. However, six months after the surgery, complete remission of negative body image symptoms was observed in all patients (extreme concern and dissatisfaction with body image associated with clinically significant distress) was verified, confirming positive impact of mammaplasty in the assessed population. Only one patient in the NSBG group had negative body image symptoms, which characterize BDD. After further investigation, it was observed that this dissatisfaction was related to the hip region and not to the breasts. As no intervention was performed to solve this problem, this condition remained after 6 months. It is noteworthy that after the study completion, this patient was instructed to undergo a medical consultation for further investigation. The literature indicates divergent points of view regarding the indication of plastic surgery for patients with BDD symptoms. Retrospective studies have questioned the benefits of performing plastic surgery in these patients.21,49 However, prospective studies have suggested that surgery may result in the reduction and even remission of negative body image symptoms in patients with mild to moderate symptoms of BDD.29,33-35,50,51 The present study had some limitations, which should be considered in the interpretation of its results. One of them was the quasi-interventional design with convenience sampling. A randomized clinical trial, in which women with breast hypertrophy would be randomly allocated to undergo or not the reduction mammaplasty would increase the external validity of the study. However, this type of design makes patient selection difficult, since many women do not accept the possibility of being allocated to the group that does not undergo the surgical procedure, since all of them have breast hypertrophy and wish to be treated for this condition. Thus, considering that all surgeries were performed through the public health system, at no cost to patients, it was considered that evaluating patients who already had their scheduled surgeries who would be submitted to the operation regardless of their participation in the study would reduce the risk of responses that would increase the symptoms in order to obtain the surgery. Since the studied groups had a selection bias, as they had different sociodemographic profiles, it would be advisable for future studies to consider these criteria for group choice. The wide age range was also a limiting factor. As previously described, the desires are different in each period of life. Even though the study involved only adult women, the age variation within this group was broad, interfering with the comparison, since the perspectives and desires of a 20-year-old young woman are different from those of a 50-year-old woman. Another limitation was the time of follow up. Although previous studies,9,15,23,43 considered six months as an adequate length of time for good follow up, the study follow-up period was a limiting factor. As body image is influenced by labile variables and undergoes constant reconstruction, it would be interesting to follow its evolution for more fragmented periods, as well as in the long term. The follow up predicted in the original project, which was approved by the Ethics Committee, consisted of only six months. However, there is an intention to evaluate these patients later on. For this purpose, it will be necessary to submit a new project to the Ethics Committee for approval. If authorized, as the contact data of the volunteers are recorded in both the files of the present study and in the hospital records, the researchers can contact the women to perform a new interview at a late follow up period. Although it has been described that the main factor that motivates the search for plastic surgery is the dissatisfaction with one’s body image,6,19,37,43 few studies have investigated the effects of breast hypertrophy and reduction mammaplasty on body image,21-23 mainly evaluating the different nuances that this construct can express. Moreover, no study that used the BIS or BEQ questionnaires for this type of evaluation has been published to date. The present study was also innovative as it compared women submitted to reduction mammaplasty with those with normal-sized breasts at two different times. CONCLUSION Women with breast hypertrophy were more dissatisfied with their breasts and more satisfied with their bodies and breast size after reduction mammaplasty to the point of surpassing the level of satisfaction and body investment of women with normal sized-breasts and no intervention. Moreover, breast reduction promoted an improvement in body image and the remission of symptoms of body dysmorphic disorder among those who had these symptoms. 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. Presented at: Women’s Health 2015: The 23rd Annual Congress in Washington, DC in April 2015. REFERENCES 1. Cosmetic Surgery National Data Bank Statistics. Aesthet Surg J . 2017; 37( suppl_2): 1- 29. 2. International Society of Aesthetic Plastic Surgery. Procedures performed in 2015. New York: International Society of Aesthetic Plastic Surgery. http://www.isaps.org/news/iasps-global-statistics. Accessed December 4, 2017. 3. American Society of Plastic Surgeons. ASPS Recommended Insurance Coverage Criteria for Third-Party Payers. Reduction Mammaplasty. Approved by the Executive Committee of the American Society of Plastic Surgeons. https://www.plasticsurgery.org/Documents/Health-Policy/Reimbursement/Insurance_2011_reduction_mammaplasty.pdf. Accessed April 22, 2017. 4. American Society of Plastic Surgeons. Evidence-based Clinical Practice Guideline: Reduction Mammaplasty, Reduction Mammaplasty. Approved by the Executive Committee of the American Society of Plastic Surgeons. https://d2wirczt3b6wjm.cloudfront.net/Health-Policy/Guidelines/guideline-2011-reduction-mammaplasty.pdf. Accessed April 22, 2017. 5. Singh KA, Losken A. Additional benefits of reduction mammaplasty: a systematic review of the literature. Plast Reconstr Surg . 2012; 129( 3): 562- 570. Google Scholar CrossRef Search ADS PubMed  6. Sarwer DB, Polonsky HM. Body Image and Body Contouring Procedures. Aesthet Surg J . 2016; 36( 9): 1039- 1047. Google Scholar CrossRef Search ADS PubMed  7. Sabino Neto M, Demattê MF, Freire M, Garcia EB, Quaresma M, Ferreira LM. Self-esteem and functional capacity outcomes following reduction mammaplasty. Aesthet Surg J . 2008; 28( 4): 417- 420. Google Scholar CrossRef Search ADS PubMed  8. Neto MS, Abla LE, Lemos ALet al.   The impact of surgical treatment on the self-esteem of patients with breast hypertrophy, hypomastia, or breast asymmetry. Aesthetic Plast Surg . 2012; 36( 1): 223- 225. Google Scholar CrossRef Search ADS PubMed  9. Mello AA, Domingos NA, Miyazaki MC. Improvement in quality of life and self-esteem after breast reduction surgery. Aesthetic Plast Surg . 2010; 34( 1): 59- 64. Google Scholar CrossRef Search ADS PubMed  10. Garcia ES, Veiga DF, Sabino-Neto Met al.   Sensitivity of the Nipple-Areola Complex and Sexual Function Following Reduction Mammaplasty. Aesthet Surg J . 2015; 35( 7): NP193- NP202. Google Scholar CrossRef Search ADS PubMed  11. Beraldo FN, Veiga DF, Veiga-Filho Jet al.   Sexual Function and Depression Outcomes Among Breast Hypertrophy Patients Undergoing Reduction Mammaplasty: A Randomized Controlled Trial. Ann Plast Surg . 2016; 76( 4): 379- 382. Google Scholar CrossRef Search ADS PubMed  12. Cabral IV, Garcia ED, Sobrinho RNet al.   Increased Capacity for Work and Productivity After Breast Reduction. Aesthet Surg J . 2017; 37( 1): 57- 62. Google Scholar CrossRef Search ADS PubMed  13. Benditte-Klepetko H, Leisser V, Paternostro-Sluga Tet al.   Hypertrophy of the breast: A problem of beauty or health? J Womens Health (Larchmt) . 2007; 16( 7): 1062- 1069. Google Scholar CrossRef Search ADS PubMed  14. Freire M, Neto MS, Garcia EB, Quaresma MR, Ferreira LM. Functional capacity and postural pain outcomes after reduction mammaplasty. Plast Reconstr Surg . 2007; 119( 4): 1149- 56; discussion 1157. Google Scholar CrossRef Search ADS PubMed  15. O’Blenes CA, Delbridge CL, Miller BJ, Pantelis A, Morris SF. Prospective study of outcomes after reduction mammaplasty: long-term follow-up. Plast Reconstr Surg . 2006; 117( 2): 351- 358. Google Scholar CrossRef Search ADS PubMed  16. Panzano EP, Catalán AG, Domínguez RS, Lasfuentes PC, Campayo JG, Sánchez AG. Reduction Mammaplasty Improves Levels of Anxiety, Depression and Body Image Satisfaction in Patients with Symptomatic Macromastia in the Short and Long Term. J Psychosom Obstet Gynaecol . 2017; 11: 1- 11. 17. Sarwer DB, Crerand CE, Magee L. Body dysmorphic disorder in patients who seek appearance-enhancing medical treatments. Oral Maxillofac Surg Clin North Am . 2010; 22( 4): 445- 453. Google Scholar CrossRef Search ADS PubMed  18. Phillips KA, Didie ER, Feusner J, Wilhelm S. Body dysmorphic disorder: treating an underrecognized disorder. Am J Psychiatry . 2008; 165( 9): 1111- 1118. Google Scholar CrossRef Search ADS PubMed  19. Reardon R, Grogan S. Women’s reasons for seeking breast reduction: a qualitative investigation. J Health Psychol . 2011; 16( 1): 31- 41. Google Scholar CrossRef Search ADS PubMed  20. Coriddi M, Nadeau M, Taghizadeh M, Taylor A. Analysis of satisfaction and well-being following breast reduction using a validated survey instrument: the BREAST-Q. Plast Reconstr Surg . 2013; 132( 2): 285- 290. Google Scholar CrossRef Search ADS PubMed  21. Sarwer DB, Bartlett SP, Bucky LPet al.   Bigger Is Not Always Better: Body Image Dissatisfaction in Breast Reduction and Breast Augmentation Patients. Plast Reconstr Surg . 1998; 101( 7): 1956- 61. Google Scholar CrossRef Search ADS PubMed  22. Glatt BS, Sarwer DB, O’Hara DE, Hamori C, Bucky LP, LaRossa D. A retrospective study of changes in physical symptoms and body image after reduction mammaplasty. Plast Reconstr Surg . 1999; 103( 1): 76- 82; discussion 83. Google Scholar CrossRef Search ADS PubMed  23. Rogliani M, Gentile P, Labardi L, Donfrancesco A, Cervelli V. Improvement of physical and psychological symptoms after breast reduction. J Plast Reconstr Aesthet Surg . 2009; 62( 12): 1647- 1649. Google Scholar CrossRef Search ADS PubMed  24. Sacchini V, Luini A, Tana S, Lozza L, Galimberti V, Merson M. Quantitative and qualitative cosmetic evaluation after conservative treatment for breast cancer. Eur J Cancer . 1991; 27( 12): 1395- 400. Google Scholar CrossRef Search ADS PubMed  25. World Health Organization. Global Database on Body Mass Index. http://apps.who.int/bmi/index.jsp. Accessed April 22, 2017. 26. Gust MJ, Smetona JT, Persing JS, Hanwright PJ, Fine NA, Kim JY. The impact of body mass index on reduction mammaplasty: a multicenter analysis of 2492 patients. Aesthet Surg J . 2013; 33( 8): 1140- 1147. Google Scholar CrossRef Search ADS PubMed  27. Rosen JC, Reiter J. Development of the body dysmorphic disorder examination. Behav Res Ther . 1996; 34 ( 9): 755- 766. Google Scholar CrossRef Search ADS PubMed  28. Jorge RT, Sabino Neto M, Natour J, Veiga DF, Jones A, Ferreira LM. Brazilian version of the body dysmorphic disorder examination. Sao Paulo Med J . 2008; 126( 2): 87- 95. Google Scholar CrossRef Search ADS PubMed  29. Brito MJ, Nahas FX, Cordás TAet al.   Prevalence of Body Dysmorphic Disorder Symptoms and Body Weight Concerns in Patients Seeking Abdominoplasty. Aesthet Surg J . 2016; 36( 3): 324- 332. Google Scholar CrossRef Search ADS PubMed  30. Gouveia VV, Santos CA, Gouveia RSV, Santos WS, Pronk SL. Escala de Investimento Corporal (BIS): Evidências de sua Validade Fatorial e Consistência Interna. Aval Psicol . 2008; 7( 1): 57- 66. 31. Moreira H, Silva S, Marques A, Canavarro MC. The Portuguese version of the body image scale (BIS) - psychometric properties in a sample of breast cancer patients. Eur J Oncol Nurs . 2010; 14( 2): 111- 118. Google Scholar CrossRef Search ADS PubMed  32. Ferreira LF, Sabino Neto M, Silva MMA, Resende VCL, Ferreira LM. Brazilian version of the Breast Evaluation Questionnaire: cultural adaptation and validation. Rev Bras Cir Plast . 2013; 28( 2): 270- 5. Google Scholar CrossRef Search ADS   33. de Brito MJ, Nahas FX, Cordás TA, Tavares H, Ferreira LM. Body Dysmorphic Disorder in Patients Seeking Abdominoplasty, Rhinoplasty, and Rhytidectomy. Plast Reconstr Surg . 2016; 137( 2): 462- 471. Google Scholar CrossRef Search ADS PubMed  34. de Brito MJ, Nahas FX, Ortega NRet al.   Support system for decision making in the identification of risk for body dysmorphic disorder: a fuzzy model. Int J Med Inform . 2013; 82( 9): 844- 853. Google Scholar CrossRef Search ADS PubMed  35. Felix GA, de Brito MJ, Nahas FXet al.   Patients with mild to moderate body dysmorphic disorder may benefit from rhinoplasty. J Plast Reconstr Aesthet Surg . 2014; 67( 5): 646- 654. Google Scholar CrossRef Search ADS PubMed  36. Purohit S. Reduction Mammaplasty. Indian J Plast Surg . 2008; 41( Suppl 1): 64- 79. 37. Borkenhagen A, Rohricht F, Schneider W, Brahler E. Changes in Body Image and Heath Relates Quality of Life Following Breast Reduction Surgery in German Macromastia Patients. Ann Plast Surg . 2007; 58: 364- 70. Google Scholar CrossRef Search ADS PubMed  38. Thoma A, Sprague S, Veltri K, Duku E, Furlong W. A prospective study of patients undergoing breast reduction surgery: health-related quality of life and clinical outcomes. Plast Reconstr Surg . 2007; 120( 1): 13- 26. Google Scholar CrossRef Search ADS PubMed  39. Kerrigan CL, Collins ED, Striplin Det al.   The Health Burden of Breast Hypertrophy. Plast Reconst Surg . 2001; 18( 6): 1591- 99. Google Scholar CrossRef Search ADS   40. Collins ED, Kerrigan CL, Kim Met al.   The effectiveness of surgical and nonsurgical interventions in relieving the symptoms of macromastia. Plast Reconstr Surg . 2002; 109( 1): 1556- 66. Google Scholar CrossRef Search ADS PubMed  41. Pruis TA, Janowsky JS. Assessment of body image in younger and older women. J Gen Psychol . 2010; 137( 3): 225- 238. Google Scholar CrossRef Search ADS PubMed  42. Spector JA, Singh SP, Karp NS. Outcomes after breast reduction: does size really matter? Ann Plast Surg . 2008; 60( 5): 505- 509. Google Scholar CrossRef Search ADS PubMed  43. Saariniemi K, Luukkala T, Kuokkanen H. The outcome of reduction mammaplasty is affected more by psychosocial factors than by changes in breast dimensions. Scand J Surg . 2011; 100( 2): 105- 109. Google Scholar CrossRef Search ADS PubMed  44. Gonzalez MA, Glickman LT, Aladegbami B, Simpson RL. Quality of Life after Breast Reduction Surgery: a 10 Year Retrospective Analysis using the Breast Questionnaire. Ann Plast Surg . 2012; 69( 4): 361- 3. Google Scholar CrossRef Search ADS PubMed  45. Shah R, Al-Ajam Y, Stott D, Kang N. Obesity in mammaplasty: a study of complications following breast reduction. J Plast Reconstr Aesthet Surg . 2011; 64( 4): 508- 514. Google Scholar CrossRef Search ADS PubMed  46. Chen CL, Shore AD, Johns R, Clark JM, Manahan M, Makary MA. The impact of obesity on breast surgery complications. Plast Reconstr Surg . 2011; 128( 5): 395e- 402e. Google Scholar CrossRef Search ADS PubMed  47. Cafri G, Yamamiya Y, Brannick M, Thompson K. The influence of Sociocultural Factors on Body Image: A Meta-Analysis. Clin Psychol . 2005; 12( 4): 421- 428. 48. Metcalfe DB, Duggal CS, Gabriel A, Nahabedian MY, Carlson GW, Losken A. Prevalence of Body Dysmorphic Disorder among patients seeking breast reconstruction. Aesthetic Plast Surg . 2014; 34( 45): 733- 737. Google Scholar CrossRef Search ADS   49. Crerand CE, Franklin ME, Sarwer DB. Body dysmorphic disorder and cosmetic surgery. Plast Reconstr Surg . 2006; 118( 7): 167e- 180e. Google Scholar CrossRef Search ADS PubMed  50. Veale D, De Haro L, Lambrou C. Cosmetic rhinoplasty in body dysmorphic disorder. Br J Plast Surg . 2003; 56( 6): 546- 551. Google Scholar CrossRef Search ADS PubMed  51. Veale D, Naismith I, Eshkevari Eet al.   Psychosexual outcome after labiaplasty: a prospective case-comparison study. Int Urogynecol J . 2014; 25( 6): 831- 839. Google Scholar CrossRef Search ADS PubMed  © 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Aesthetic Surgery Journal Oxford University Press

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Abstract

Abstract Background Body image dissatisfaction is one of the major factors that motivate patients to undergo plastic surgery. However, few studies have associated body satisfaction with reduction mammaplasty. Objectives The aim of this study was to evaluate the impact of breast hypertrophy and reduction mammaplasty on body image. Methods Breast hypertrophy patients, with reduction mammaplasty already scheduled between June 2013 and December 2015 (mammaplasty group, MG), were prospectively evaluated through the body dysmorphic disorder examination (BDDE), body investment scale (BIS), and breast evaluation questionnaire (BEQ55) tools. Women with normal-sized breasts were also evaluated as study controls (normal-sized breast group, NSBG). All the participants were interviewed at the initial assessment and after six months. Data were analyzed before and after six months. Results Each group consisted of 103 women. The MG group had a significant improvement in BDDE, BIS, and BEQ55 scores six months postoperatively (P ≤ 0.001 for the three instruments), whereas the NSBG group showed no alteration in results over time (P = 0.876; P = 0.442; and P = 0.184, respectively). In the intergroup comparison it was observed that the MG group began to invest more in the body, similarly to the NSBG group, and surpassed the level of satisfaction and body image that the women of the NSBG group had after the surgery. Conclusions Reduction mammaplasty promoted improvement in body image of women with breast hypertrophy. Level of Evidence: 2 The wish to change breast size is a complex and multifactorial one; variables such as beauty ideal, self-confidence, self-esteem, and body image have led women of all age groups to seek plastic surgery.1-6 Body image is the representation of one’s physical appearance, the result of a combination of perceptual-neural processes, environmental, social, and psychological factors. Its is expressed through the degree of care and satisfaction with one’s body.6 Breast hypertrophy is characterized by enlarged breasts, disproportionate to the woman’s biotype. The body imbalance caused by the hypertrophy leads to physical dysfunctions, psychological disorders, and a sense of social inadequacy.7-12 Several studies have shown that breast hypertrophy leads to postural changes, shoulder and spinal pain, and functional limitations, which at more advanced degrees can impair even the activities of daily living.7-9 Excess volume and skin flaccidity limit physical activity and reduce women’s ability to work, as well as their productivity.12-14 Breast hypertrophy can also interfere with women’s affective and social relations by triggering feelings of insecurity regarding their own bodies, expressed as behaviors of avoidance of outdoor activities, or in public and social settings and situations of intimacy. This dynamic generates feelings of low self-esteem and anxiety, which can lead to depression. Women with breast hypertrophy report the difficulty of finding clothes that fit the size of their breasts and claim that they often avoid social situations because they feel inadequate.5,7,10,11,15,16 Therefore, excess breast volume may be associated with morbidity levels that go beyond a simple esthetic alteration and require effective treatment.13,17,18 Reduction mammaplasty aims at decreasing breast size, and restoring the symmetry of the female chest dimensions. With advances in surgical techniques and increasingly positive results, plastic surgery is now considered a means of transforming one’s external appearance and a resource capable of improving dissatisfaction with body image. Thus, it is believed that reduction mammaplasty can bring significant benefits to body image and emotional health.6,16,19 Despite several studies on the positive effects of reduction mammaplasty on the physical, psychological, and social aspects,8-12,20 few studies have investigated the effects of breast hypertrophy and reduction mammaplasty on body image.21-23 Thus, the aim of this study was to evaluate the impact of breast hypertrophy and reduction mammaplasty on body image. METHODS This was an observational study carried out between June 2013 and June 2016, involving 206 women, 103 with normal-sized breasts (normal-sized breast group - NSBG) and 103 with breast hypertrophy with scheduled reduction mammaplasty (mammaplasty group - MG). The project was approved by the Ethics Committees of Universidade Federal de São Paulo (CAAE: 30223214.2.0000.5505, Opinion n. 639.052/2014) and of Universidade do Vale do Sapucaí (CAAE: 15167713.9.0000.5102 Opinion n. 303.366/2013). The MG group was a convenience sample, consisting of all patients scheduled for reduction mammaplasty at the plastic surgery service funded by the Brazilian Public Health System (SUS) of a Brazilian university hospital. The women from the NSBG group were selected from the Gynecology - Family Planning outpatient clinics of the same hospital and during the same evaluation period as the MG group. Women between 18 and 55 years of age and body mass index (BMI) < 30 kg/m2, with breast hypertrophy according to the criterion of Sacchini et al,24 who met the eligibility criteria and had already had the operation scheduled from June 2013 to December 2015 were included in the study. The criterion of Sacchini et al24 considers the mean measurements of the distance between the mammary papilla and the inframammary fold and between the nipple and the lateral border of the sternum. A mean value <9 cm indicates small breasts, between 9 and 11 cm, breasts of normal volume and >11 cm large breasts, with hypertrophy. The patients were evaluated after the previously scheduled surgery to avoid the bias of overestimating breast alteration in preoperative evaluations aiming to obtain free surgery through the public health system. For inclusion in the NSBG group, the women should have breasts considered of normal size according to the same index (mean between 9 and 11 cm). Normal-sized breast refers to a medium-sized breast, proportional to the woman’s biotype.24 To be included in this group women should not have undergone any previous surgical procedure on the breasts, and not have the wish to apply for plastic surgery. The exclusion criteria for both groups were age <18 or >55 years, BMI >30 kg/m2, pregnancy, childbirth or breastfeeding within one year, menopause, current or past history of psychiatric treatment, uncontrolled acute or systemic diseases, breast disease diagnosed or under investigation, or prior breast surgeries. Prior to data collection, all volunteers were informed about the study objectives and ethical aspects, ensuring their anonymity, confidentiality of the received information, and the freedom to withdraw their participation at any time during the study. All those who agreed to participate signed the Free and Informed Consent form. Firstly, a physical examination was performed to assess BMI and breast size.25,26 Next, the participants’ sociodemographic, economic, and clinical data were collected. Finally, three body image assessment tools that have been validated for use in Brazil, were applied through an interview guided by the researchers. The tools body dysmorphic disorder examination (BDDE),27–29 body investment scale (BIS),30,31 and breast evaluation questionnaire (BEQ 55)32 were used. The BDDE investigates negative aspects of body image, such as concern over and excessive importance assigned to one’s physical appearance, negative self-assessment, shame, embarrassment and avoidance behaviors in public and social situations, or situations of physical contact, use of camouflage strategies and body-checking behaviors.27-29 The tool was culturally validated to be used in interviews27 and is also capable of detecting symptoms of body dysmorphic disorder (BDD).18,28,29,33 The presence of BDD symptoms are classified as mild to moderate and severe according to the studies by de Brito et al34 and Félix et al.35 The BIS assesses the emotional investment in one’s body. This scale consists of 20 items, which evaluate factors such as body image, body care, and body touch. A high score indicates positive feelings about one’s body.30,31 The breast evaluation questionnaire (BEQ 55) consists of 55 items that evaluate the satisfaction with the size, shape, and firmness of one’s breasts, in relation to the sexual, social, or professional aspects, as well as the degree of comfort with one’s general appearance, breast appearance when covered by clothes, in a bathing suit, and naked, when alone or in the presence of others. It also assesses the importance of breast size to oneself and to other people in one’s relationships. The higher the score obtained in this questionnaire, the greater the satisfaction with one’s breasts. The BEQ 55 was culturally validated for Brazil among the plastic surgery population.32 In the MG group, the evaluations were carried out at the preoperative appointment at the outpatient clinic at least two weeks before the surgery (to prevent preoperative anxiety and nervousness from influencing responses) and at the six-month postoperative return. In the NSBG group, the interview was performed during the appointment at the outpatient clinic after physical evaluation to include the participants in the study and six months later, by scheduled appointment. All women, from both groups, were reminded of their sixth month return visit by telephone on the week of the appointment. The patients in the MG group were operated on by the same team of surgeons. The surgical technique used was a standardized and conventional one, with the breast reduction procedure being performed with a resulting inverted “T” scar and flap with superomedial pedicle for the elevation of the areola-papillary complex.9,22,36 Statistical Analysis The SPSS program (Statistical Package for Social Sciences, Inc., Chicago, IL), version 19.0, was used for the statistical analyses. Quantitative data were described as means and standard deviations. For the inferential statistics, the chi-square test was used to compare the groups regarding the socioeconomic profile, the t test for comparison of ages and BMI, the paired t test was used to analyze breast size, and analysis of variance (ANOVA) with repeated measurements was used to analyze the scores of body image questionnaires. The obtained scores were compared between the MG and NSBG groups (intergroup comparison) and within the same group (intragroup comparison) over the six-month period. The means were adjusted statistically by mixed-effect models to consider the observed sociodemographic differences. The level of significance used for all analyses was set at 5%. RESULTS There were no losses or exclusions in either of the groups, and all 206 volunteers (103 NSBG women and 103 MG patients) completed the follow up. The participants’ ages ranged from 18 to 55 years in both groups (mean, 32.5 years [NSBG] and 33.7 years [MG]). Table 1 presents the sociodemographic characteristics of women in both groups. Table 1. Physical and Sociodemographic Characteristics of the Assessed Groups   Group  P-value  Normal-sized breasts (n = 103)   Mammaplasty (n = 103)   Age (years)      t test   Mean ± SD  32.50 ± 11.35  33.73 ± 11.27  0.435   Range  18 - 55  18 - 55  —  Schooling level, n (%)      chi-square   Elementary school  7 (6.8%)  25 (24.3%)  —   High school  46 (44.7%)  52 (50.5%)  <0.001*   College/university  29 (28.2%)  18 (17.5%)  —   Postgraduate  21 (20.4%)  8 (7.8%)  —  Marital status, n (%)      chi-square   Single  63 (61.2%)  40 (38.8%)  —   Married  35 (34%)  51 (49.5%)  —   Divorced  4 (3.9%)  8 (7.8%)  <0.001*   Widowed  1 (1%)  4 (3.9%)  —  Children, n (%)      chi-square   Yes  41 (39.8%)  66 (64.1%)  <0.001*   No  62 (60.2%)  37 (35.9%)  —  Sacchini Index (cm)      Paired t test   Mean ± SD  9.95 ± 0.90  14.46 ± 1.77  <0.001*   Range  7.50 - 10.75  11.50 - 19.50  —  Resected weight (g)   Mean ± SD  N/A  732.05 ± 362.01  —   Range  N/A  300 - 2700  —    Group  P-value  Normal-sized breasts (n = 103)   Mammaplasty (n = 103)   Age (years)      t test   Mean ± SD  32.50 ± 11.35  33.73 ± 11.27  0.435   Range  18 - 55  18 - 55  —  Schooling level, n (%)      chi-square   Elementary school  7 (6.8%)  25 (24.3%)  —   High school  46 (44.7%)  52 (50.5%)  <0.001*   College/university  29 (28.2%)  18 (17.5%)  —   Postgraduate  21 (20.4%)  8 (7.8%)  —  Marital status, n (%)      chi-square   Single  63 (61.2%)  40 (38.8%)  —   Married  35 (34%)  51 (49.5%)  —   Divorced  4 (3.9%)  8 (7.8%)  <0.001*   Widowed  1 (1%)  4 (3.9%)  —  Children, n (%)      chi-square   Yes  41 (39.8%)  66 (64.1%)  <0.001*   No  62 (60.2%)  37 (35.9%)  —  Sacchini Index (cm)      Paired t test   Mean ± SD  9.95 ± 0.90  14.46 ± 1.77  <0.001*   Range  7.50 - 10.75  11.50 - 19.50  —  Resected weight (g)   Mean ± SD  N/A  732.05 ± 362.01  —   Range  N/A  300 - 2700  —  N/A, not applicable; SD, standard deviation. *P ≤ 0.05. View Large Table 1. Physical and Sociodemographic Characteristics of the Assessed Groups   Group  P-value  Normal-sized breasts (n = 103)   Mammaplasty (n = 103)   Age (years)      t test   Mean ± SD  32.50 ± 11.35  33.73 ± 11.27  0.435   Range  18 - 55  18 - 55  —  Schooling level, n (%)      chi-square   Elementary school  7 (6.8%)  25 (24.3%)  —   High school  46 (44.7%)  52 (50.5%)  <0.001*   College/university  29 (28.2%)  18 (17.5%)  —   Postgraduate  21 (20.4%)  8 (7.8%)  —  Marital status, n (%)      chi-square   Single  63 (61.2%)  40 (38.8%)  —   Married  35 (34%)  51 (49.5%)  —   Divorced  4 (3.9%)  8 (7.8%)  <0.001*   Widowed  1 (1%)  4 (3.9%)  —  Children, n (%)      chi-square   Yes  41 (39.8%)  66 (64.1%)  <0.001*   No  62 (60.2%)  37 (35.9%)  —  Sacchini Index (cm)      Paired t test   Mean ± SD  9.95 ± 0.90  14.46 ± 1.77  <0.001*   Range  7.50 - 10.75  11.50 - 19.50  —  Resected weight (g)   Mean ± SD  N/A  732.05 ± 362.01  —   Range  N/A  300 - 2700  —    Group  P-value  Normal-sized breasts (n = 103)   Mammaplasty (n = 103)   Age (years)      t test   Mean ± SD  32.50 ± 11.35  33.73 ± 11.27  0.435   Range  18 - 55  18 - 55  —  Schooling level, n (%)      chi-square   Elementary school  7 (6.8%)  25 (24.3%)  —   High school  46 (44.7%)  52 (50.5%)  <0.001*   College/university  29 (28.2%)  18 (17.5%)  —   Postgraduate  21 (20.4%)  8 (7.8%)  —  Marital status, n (%)      chi-square   Single  63 (61.2%)  40 (38.8%)  —   Married  35 (34%)  51 (49.5%)  —   Divorced  4 (3.9%)  8 (7.8%)  <0.001*   Widowed  1 (1%)  4 (3.9%)  —  Children, n (%)      chi-square   Yes  41 (39.8%)  66 (64.1%)  <0.001*   No  62 (60.2%)  37 (35.9%)  —  Sacchini Index (cm)      Paired t test   Mean ± SD  9.95 ± 0.90  14.46 ± 1.77  <0.001*   Range  7.50 - 10.75  11.50 - 19.50  —  Resected weight (g)   Mean ± SD  N/A  732.05 ± 362.01  —   Range  N/A  300 - 2700  —  N/A, not applicable; SD, standard deviation. *P ≤ 0.05. View Large Only two (1.94%) of the 103 patients submitted to the mammaplasty had postoperative complications. Both had a small surgical wound dehiscence, which was resolved with dressings without the need for any complementary surgical procedure. In both cases, the complication was completely resolved at the six-month assessment. Table 2 describes the results of the comparison of intra- and intergroup BMI before and after six months, with means adjusted for the differences of the groups in relation to age, marital status, schooling, and children. Patients in the MG group had a higher BMI than those in the NSBG group at the first evaluation (P < 0.001) and showed weight gain after the surgery (P = 0.016) (Table 2). Table 2. BMI Comparison Over Time in the NSBG and MG Groups Variable/assessment moment   Group   Intergroup comparisons (ANOVA)   Normal-sized breasts (n = 103)   Mammaplasty (n = 103)   BMI (kg/m2)   Before  22.84 ± 0.33  24.61 ± 0.26  <0.001*   Range  16.90 - 28.12  20.43 - 28.80  —   After  22.95 ± 0.40  25.18 ± 0.31  <0.001*   Range  17.24 - 29.72  20.14 - 34.55  —  Intragroup comparisons (ANOVA)  0.699  0.016*  —  Variable/assessment moment   Group   Intergroup comparisons (ANOVA)   Normal-sized breasts (n = 103)   Mammaplasty (n = 103)   BMI (kg/m2)   Before  22.84 ± 0.33  24.61 ± 0.26  <0.001*   Range  16.90 - 28.12  20.43 - 28.80  —   After  22.95 ± 0.40  25.18 ± 0.31  <0.001*   Range  17.24 - 29.72  20.14 - 34.55  —  Intragroup comparisons (ANOVA)  0.699  0.016*  —  SE, standard error. # Adjusted for age, marital status, level of schooling, and children. * P < 0.05. View Large Table 2. BMI Comparison Over Time in the NSBG and MG Groups Variable/assessment moment   Group   Intergroup comparisons (ANOVA)   Normal-sized breasts (n = 103)   Mammaplasty (n = 103)   BMI (kg/m2)   Before  22.84 ± 0.33  24.61 ± 0.26  <0.001*   Range  16.90 - 28.12  20.43 - 28.80  —   After  22.95 ± 0.40  25.18 ± 0.31  <0.001*   Range  17.24 - 29.72  20.14 - 34.55  —  Intragroup comparisons (ANOVA)  0.699  0.016*  —  Variable/assessment moment   Group   Intergroup comparisons (ANOVA)   Normal-sized breasts (n = 103)   Mammaplasty (n = 103)   BMI (kg/m2)   Before  22.84 ± 0.33  24.61 ± 0.26  <0.001*   Range  16.90 - 28.12  20.43 - 28.80  —   After  22.95 ± 0.40  25.18 ± 0.31  <0.001*   Range  17.24 - 29.72  20.14 - 34.55  —  Intragroup comparisons (ANOVA)  0.699  0.016*  —  SE, standard error. # Adjusted for age, marital status, level of schooling, and children. * P < 0.05. View Large Regarding body image assessment, Table 3 shows the results obtained for the BDDE, BIS, and BEQ55 questionnaire comparisons, with means adjusted for the differences in the groups regarding age, marital status, schooling, and children. In the intergroup comparisons, significant differences were observed between the NSBG and the MG groups for BDDE and BEQ55 scores, both at the initial assessment and after 6 months (P < 0.001 for all the comparisons) and for the BIS scores at the initial assessment only (P < 0.001). In the intragroup comparison, no significant difference was observed between the initial evaluation and after 6 months in the NSBG group, for any of the applied tools. But the MG group showed improvement at the 6-month postoperative period (P < 0.001 for the three questionnaires) (Table 3). Table 3. Comparison Within and Between Groups of the Scores of the BDDE, BIS, and BEQ Questionnaires* Scores/evaluation period   Group   Intergroup comparison (ANOVA)   Normal-sized breasts (n = 103)   Mammaplasty (n = 103)   BDDE   Before   Mean ± SE  37.43 ± 3.77  87.04 ± 2.92  <0.001*   Range  32.12 - 41.40  81.61 - 90.89  —   After   Mean ± SE  37.99 ± 2.08  24.13 ± 1.61*  <0.001*   Range  33.59 - 38.66  20.35 - 25.42  —   Intragroup comparison (ANOVA)  0.876  <0.001*  —  BIS   Before   Mean ± SE  82.99 ± 1.21  71.35 ± 0,94  <0.001*   Range  81.52 - 84.45  70.32 - 73.26  —   After   Mean ± SE  81.94 ± 1.00  83.71 ± 0.77*  0.157   Range  80.39 - 82.94  82.99 - 85.54  —   Intragroup comparison (ANOVA)  0.442  <0.001*  —  BEQ   Before   Mean ± SE  197.75 ± 4.57  114.93 ± 3.53  <0.001   Range  191.64 - 202.47  109.30 - 120.13  —   After   Mean ± SE  203.82 ± 4.40  230.68 ± 3.41*  <0.001*   Range  199.39 - 209.98  226.95 - 237.54  —   Intragroup comparison (ANOVA)  0.184  <0.001*  —  Scores/evaluation period   Group   Intergroup comparison (ANOVA)   Normal-sized breasts (n = 103)   Mammaplasty (n = 103)   BDDE   Before   Mean ± SE  37.43 ± 3.77  87.04 ± 2.92  <0.001*   Range  32.12 - 41.40  81.61 - 90.89  —   After   Mean ± SE  37.99 ± 2.08  24.13 ± 1.61*  <0.001*   Range  33.59 - 38.66  20.35 - 25.42  —   Intragroup comparison (ANOVA)  0.876  <0.001*  —  BIS   Before   Mean ± SE  82.99 ± 1.21  71.35 ± 0,94  <0.001*   Range  81.52 - 84.45  70.32 - 73.26  —   After   Mean ± SE  81.94 ± 1.00  83.71 ± 0.77*  0.157   Range  80.39 - 82.94  82.99 - 85.54  —   Intragroup comparison (ANOVA)  0.442  <0.001*  —  BEQ   Before   Mean ± SE  197.75 ± 4.57  114.93 ± 3.53  <0.001   Range  191.64 - 202.47  109.30 - 120.13  —   After   Mean ± SE  203.82 ± 4.40  230.68 ± 3.41*  <0.001*   Range  199.39 - 209.98  226.95 - 237.54  —   Intragroup comparison (ANOVA)  0.184  <0.001*  —  P obtained from repeated measures ANOVA. ANOVA, analysis of variance; BDDE, body dysmorphic disorder examination; BEQ, breast evaluation questionnaire; BIS, body investment scale; SE, standard error. * Values in mean ± standard error, adjusted for age, marital status, education, and motherhood. View Large Table 3. Comparison Within and Between Groups of the Scores of the BDDE, BIS, and BEQ Questionnaires* Scores/evaluation period   Group   Intergroup comparison (ANOVA)   Normal-sized breasts (n = 103)   Mammaplasty (n = 103)   BDDE   Before   Mean ± SE  37.43 ± 3.77  87.04 ± 2.92  <0.001*   Range  32.12 - 41.40  81.61 - 90.89  —   After   Mean ± SE  37.99 ± 2.08  24.13 ± 1.61*  <0.001*   Range  33.59 - 38.66  20.35 - 25.42  —   Intragroup comparison (ANOVA)  0.876  <0.001*  —  BIS   Before   Mean ± SE  82.99 ± 1.21  71.35 ± 0,94  <0.001*   Range  81.52 - 84.45  70.32 - 73.26  —   After   Mean ± SE  81.94 ± 1.00  83.71 ± 0.77*  0.157   Range  80.39 - 82.94  82.99 - 85.54  —   Intragroup comparison (ANOVA)  0.442  <0.001*  —  BEQ   Before   Mean ± SE  197.75 ± 4.57  114.93 ± 3.53  <0.001   Range  191.64 - 202.47  109.30 - 120.13  —   After   Mean ± SE  203.82 ± 4.40  230.68 ± 3.41*  <0.001*   Range  199.39 - 209.98  226.95 - 237.54  —   Intragroup comparison (ANOVA)  0.184  <0.001*  —  Scores/evaluation period   Group   Intergroup comparison (ANOVA)   Normal-sized breasts (n = 103)   Mammaplasty (n = 103)   BDDE   Before   Mean ± SE  37.43 ± 3.77  87.04 ± 2.92  <0.001*   Range  32.12 - 41.40  81.61 - 90.89  —   After   Mean ± SE  37.99 ± 2.08  24.13 ± 1.61*  <0.001*   Range  33.59 - 38.66  20.35 - 25.42  —   Intragroup comparison (ANOVA)  0.876  <0.001*  —  BIS   Before   Mean ± SE  82.99 ± 1.21  71.35 ± 0,94  <0.001*   Range  81.52 - 84.45  70.32 - 73.26  —   After   Mean ± SE  81.94 ± 1.00  83.71 ± 0.77*  0.157   Range  80.39 - 82.94  82.99 - 85.54  —   Intragroup comparison (ANOVA)  0.442  <0.001*  —  BEQ   Before   Mean ± SE  197.75 ± 4.57  114.93 ± 3.53  <0.001   Range  191.64 - 202.47  109.30 - 120.13  —   After   Mean ± SE  203.82 ± 4.40  230.68 ± 3.41*  <0.001*   Range  199.39 - 209.98  226.95 - 237.54  —   Intragroup comparison (ANOVA)  0.184  <0.001*  —  P obtained from repeated measures ANOVA. ANOVA, analysis of variance; BDDE, body dysmorphic disorder examination; BEQ, breast evaluation questionnaire; BIS, body investment scale; SE, standard error. * Values in mean ± standard error, adjusted for age, marital status, education, and motherhood. View Large Table 4 refers to the BDDE assessment in relation to negative body image symptoms. Table 4. Severity of Negative Body Image Symptoms in the NSBG and MG Groups Patients, n (%)  MG Preoperative   MG 6 months postoperative   NSBG 1st interview   NSBG 2nd interview   No symptoms  56 (54.36%)  103 (100%)  102 (99.02%)  103 (100%)  Mild to moderate  37 (35.92%)  0  0  0  Severe  10 (9.70%)  0  1 (0.97%)  0  Patients, n (%)  MG Preoperative   MG 6 months postoperative   NSBG 1st interview   NSBG 2nd interview   No symptoms  56 (54.36%)  103 (100%)  102 (99.02%)  103 (100%)  Mild to moderate  37 (35.92%)  0  0  0  Severe  10 (9.70%)  0  1 (0.97%)  0  View Large Table 4. Severity of Negative Body Image Symptoms in the NSBG and MG Groups Patients, n (%)  MG Preoperative   MG 6 months postoperative   NSBG 1st interview   NSBG 2nd interview   No symptoms  56 (54.36%)  103 (100%)  102 (99.02%)  103 (100%)  Mild to moderate  37 (35.92%)  0  0  0  Severe  10 (9.70%)  0  1 (0.97%)  0  Patients, n (%)  MG Preoperative   MG 6 months postoperative   NSBG 1st interview   NSBG 2nd interview   No symptoms  56 (54.36%)  103 (100%)  102 (99.02%)  103 (100%)  Mild to moderate  37 (35.92%)  0  0  0  Severe  10 (9.70%)  0  1 (0.97%)  0  View Large DISCUSSION The results showed improvement in the different body image aspects assessed in women who underwent reduction mammaplasty. The normal-sized breast group (NSBG) showed more positive feelings in the first interview than the women who underwent reduction mammaplasty (MG). However, after the intervention, the MG patients were so satisfied with the surgical intervention outcome that they were as satisfied as or even more satisfied than the women in the NSBG group, as demonstrated by the scores of BEQ55. The choice of a group of women with normal-sized breasts and no surgical interventions aimed to compare the MG group with a representative sample of the female population without alterations in breast volume and evaluate whether body image and the satisfaction of the women with breast hypertrophy would reach a similar level after the intervention to that observed in the group of women with normal-sized breasts. The present study did not include women with BMI above 30 kg/m2, which characterizes obesity, in either group.25 As obesity can influence body image, it was decided not to include obese women so that any changes in body image could be attributed to breast size, not obesity. We also did not include women with a history of psychiatric treatment, because the aim of the study was to evaluate women with similar characteristics that differed regarding breast size. Mental status, although compensated by treatment, could influence the responses to the questionnaires. If the patients were undergoing psychiatric treatment, symptom improvement could be attributable to the therapy or medication and not to the surgical correction of the breast hypertrophy. The NSBG group showed more positive symptoms in relation to body image, higher level of satisfaction with the body and breasts, and similar results regarding emotional investment in the body. It is noteworthy that the NSBG group volunteers, as expected, maintained their scores for the three questionnaires at the second evaluation demonstrating that this group did not change over time. On the other hand, the MG group, which initially disclosed dissatisfaction with body image, not only improved after surgery, but showed more positive feelings about the body when compared to the NSBG group. Previous studies that used other tools to assess body image,16,37,38 as well as investigations that used the BDDE to assess the effects of breast hypertrophy and reduction mammaplasty on body image,22-24 agreed with the results obtained in this study. All of them observed that women with hypertrophic breasts had a negative body image, were dissatisfied with their appearance, were insecure, were ashamed to expose their bodies, and showed social problems due to the condition. They also described that the reduction mammaplasty resulted in greater satisfaction with breast shape, size, and symmetry. According to the authors, the patients reported feeling more feminine, attractive, confident, and less inhibited in sexual and social relationships. It was observed that the new breast became, over time, integrated into the body image and the women started to show greater satisfaction with their bodies as a whole. These results show that the positive rearrangement of the body image was not restricted to the breasts alone, but resulted in an overall feeling of well-being in relation to the body.16,22,23,37,38 The six-month reevaluation period was defined in this study, as this is the mean time for complete healing. Moreover, a reassessment after this period was described as an adequate period of time for the patient to fully incorporate the new breast size into her perception.9,15,23,37,38 Although some studies suggest that body image improvement occurs as early as after the third month of the intervention, the mammaplasty benefits were observed in both the short- and long-term assessments, showing that the positive change is almost immediately observed and remains over time.15,21-23,38 Several studies15,21-23 have suggested an assessment for longer and more frequent periods to observe patient behavior, as well as body perception and image readjustment that occurs after the surgery. The NSBG group showed positive scores for body image at the first interview, which persisted at the second evaluation, showing that the degree of satisfaction with the body was maintained throughout the six-month period. This fact was confirmed in these patients, whose breasts were within the normal anatomical limits, since they did not manifest the desire to undergo plastic surgery. The studies by Kerrigan et al39 and Collins et al40 also compared the body image of women submitted to mammaplasty with those with normal-sized breasts. Both studies observed that women with normal-sized breasts evaluated their appearance more positively when compared to those with breast hypertrophy. However, none of these studies carried out a second interview after a period of time or investigated body dysmorphic disorder symptoms in this specific population. The age of the study population ranged from 18 to 55 years. This variation was established with the purpose of assessing women who were living the same period of life (ie, adulthood). As each age category has specific body image characteristics, women older than 55 years who were likely to be approaching or were already going through menopause were excluded, as well as women under the age of 18, who were still undergoing the body transformations of adolescence.41 The patients showed significant variation in resected tissue weight. Studies such as those by Collins et al,40 Spector et al,42 Saarieniemi et al,43 and Gonzalez et al44 observed that the amount of resected tissue is not a main factor influencing body image. These studies40,42-44 indicated benefits such as symptom relief and patient well-being even after small reductions.2,3,20 It was observed that the MG patients had a higher BMI than those in NSBG group at the first evaluation and showed weight gain after the surgery. Other authors also observed weight excess in patients with breast hypertrophy and postintervention maintenance or gain of measurements.9,21,44 In these studies, the weight excess was justified due to the existence of inadequate eating habits and sedentary lifestyle, which were maintained after the intervention.45,46 However, it is worth mentioning that these same studies stated that patients with high BMI have benefits in relation to body satisfaction after the surgery, emphasizing that the problems related to breast hypertrophy are comprised of a combination of factors and that the criteria leading to a positive body image are very subjective. Thus, excess of weight, when present, might not prevent the improvement with body satisfaction and gratification.9,21,44 The groups differed regarding level of schooling, marital status, and motherhood. A limitation of the present study was that the researchers had difficulty controlling the sociodemographic profile in the groups. Although intervals for age and body mass index were defined, the criteria for eligibility included breast size (normal volume and hypertrophy) and absence of previous surgical interventions in the breasts, with social status or other demographic variables not being considered for the selection. Studies in adults that investigate the influence of variables such as level of schooling, income, marital status, and motherhood on body image are rare in the literature. These studies are not clear regarding the influence of these variables on body image, or declared there was no correlation.35,47 However, to minimize biases in the present study due to the identified differences, a statistical mechanism, the mixed-effects model, was used to neutralize the contrasts. A high prevalence of negative body image symptoms, which characterized body dysmorphic disorder (BDD), was observed in patients with breast hypertrophy submitted to mammaplasty.6 Metcalfe et al48 indicated the presence of BDD in patients submitted to reconstructive breast surgery. Although the population of the present study did not have the degree of deformity caused by mastectomy, such as that studied by Metcalfe et al,48 nevertheless, breast hypertrophy characterizes a clearly observable deformity and the authors were careful to assess the symptoms for BDD. However, six months after the surgery, complete remission of negative body image symptoms was observed in all patients (extreme concern and dissatisfaction with body image associated with clinically significant distress) was verified, confirming positive impact of mammaplasty in the assessed population. Only one patient in the NSBG group had negative body image symptoms, which characterize BDD. After further investigation, it was observed that this dissatisfaction was related to the hip region and not to the breasts. As no intervention was performed to solve this problem, this condition remained after 6 months. It is noteworthy that after the study completion, this patient was instructed to undergo a medical consultation for further investigation. The literature indicates divergent points of view regarding the indication of plastic surgery for patients with BDD symptoms. Retrospective studies have questioned the benefits of performing plastic surgery in these patients.21,49 However, prospective studies have suggested that surgery may result in the reduction and even remission of negative body image symptoms in patients with mild to moderate symptoms of BDD.29,33-35,50,51 The present study had some limitations, which should be considered in the interpretation of its results. One of them was the quasi-interventional design with convenience sampling. A randomized clinical trial, in which women with breast hypertrophy would be randomly allocated to undergo or not the reduction mammaplasty would increase the external validity of the study. However, this type of design makes patient selection difficult, since many women do not accept the possibility of being allocated to the group that does not undergo the surgical procedure, since all of them have breast hypertrophy and wish to be treated for this condition. Thus, considering that all surgeries were performed through the public health system, at no cost to patients, it was considered that evaluating patients who already had their scheduled surgeries who would be submitted to the operation regardless of their participation in the study would reduce the risk of responses that would increase the symptoms in order to obtain the surgery. Since the studied groups had a selection bias, as they had different sociodemographic profiles, it would be advisable for future studies to consider these criteria for group choice. The wide age range was also a limiting factor. As previously described, the desires are different in each period of life. Even though the study involved only adult women, the age variation within this group was broad, interfering with the comparison, since the perspectives and desires of a 20-year-old young woman are different from those of a 50-year-old woman. Another limitation was the time of follow up. Although previous studies,9,15,23,43 considered six months as an adequate length of time for good follow up, the study follow-up period was a limiting factor. As body image is influenced by labile variables and undergoes constant reconstruction, it would be interesting to follow its evolution for more fragmented periods, as well as in the long term. The follow up predicted in the original project, which was approved by the Ethics Committee, consisted of only six months. However, there is an intention to evaluate these patients later on. For this purpose, it will be necessary to submit a new project to the Ethics Committee for approval. If authorized, as the contact data of the volunteers are recorded in both the files of the present study and in the hospital records, the researchers can contact the women to perform a new interview at a late follow up period. Although it has been described that the main factor that motivates the search for plastic surgery is the dissatisfaction with one’s body image,6,19,37,43 few studies have investigated the effects of breast hypertrophy and reduction mammaplasty on body image,21-23 mainly evaluating the different nuances that this construct can express. Moreover, no study that used the BIS or BEQ questionnaires for this type of evaluation has been published to date. The present study was also innovative as it compared women submitted to reduction mammaplasty with those with normal-sized breasts at two different times. CONCLUSION Women with breast hypertrophy were more dissatisfied with their breasts and more satisfied with their bodies and breast size after reduction mammaplasty to the point of surpassing the level of satisfaction and body investment of women with normal sized-breasts and no intervention. Moreover, breast reduction promoted an improvement in body image and the remission of symptoms of body dysmorphic disorder among those who had these symptoms. 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. Presented at: Women’s Health 2015: The 23rd Annual Congress in Washington, DC in April 2015. REFERENCES 1. Cosmetic Surgery National Data Bank Statistics. Aesthet Surg J . 2017; 37( suppl_2): 1- 29. 2. International Society of Aesthetic Plastic Surgery. Procedures performed in 2015. New York: International Society of Aesthetic Plastic Surgery. http://www.isaps.org/news/iasps-global-statistics. Accessed December 4, 2017. 3. American Society of Plastic Surgeons. ASPS Recommended Insurance Coverage Criteria for Third-Party Payers. Reduction Mammaplasty. Approved by the Executive Committee of the American Society of Plastic Surgeons. https://www.plasticsurgery.org/Documents/Health-Policy/Reimbursement/Insurance_2011_reduction_mammaplasty.pdf. Accessed April 22, 2017. 4. American Society of Plastic Surgeons. Evidence-based Clinical Practice Guideline: Reduction Mammaplasty, Reduction Mammaplasty. Approved by the Executive Committee of the American Society of Plastic Surgeons. https://d2wirczt3b6wjm.cloudfront.net/Health-Policy/Guidelines/guideline-2011-reduction-mammaplasty.pdf. Accessed April 22, 2017. 5. Singh KA, Losken A. Additional benefits of reduction mammaplasty: a systematic review of the literature. Plast Reconstr Surg . 2012; 129( 3): 562- 570. Google Scholar CrossRef Search ADS PubMed  6. Sarwer DB, Polonsky HM. Body Image and Body Contouring Procedures. Aesthet Surg J . 2016; 36( 9): 1039- 1047. Google Scholar CrossRef Search ADS PubMed  7. Sabino Neto M, Demattê MF, Freire M, Garcia EB, Quaresma M, Ferreira LM. Self-esteem and functional capacity outcomes following reduction mammaplasty. Aesthet Surg J . 2008; 28( 4): 417- 420. Google Scholar CrossRef Search ADS PubMed  8. Neto MS, Abla LE, Lemos ALet al.   The impact of surgical treatment on the self-esteem of patients with breast hypertrophy, hypomastia, or breast asymmetry. Aesthetic Plast Surg . 2012; 36( 1): 223- 225. Google Scholar CrossRef Search ADS PubMed  9. Mello AA, Domingos NA, Miyazaki MC. Improvement in quality of life and self-esteem after breast reduction surgery. Aesthetic Plast Surg . 2010; 34( 1): 59- 64. Google Scholar CrossRef Search ADS PubMed  10. Garcia ES, Veiga DF, Sabino-Neto Met al.   Sensitivity of the Nipple-Areola Complex and Sexual Function Following Reduction Mammaplasty. Aesthet Surg J . 2015; 35( 7): NP193- NP202. Google Scholar CrossRef Search ADS PubMed  11. Beraldo FN, Veiga DF, Veiga-Filho Jet al.   Sexual Function and Depression Outcomes Among Breast Hypertrophy Patients Undergoing Reduction Mammaplasty: A Randomized Controlled Trial. Ann Plast Surg . 2016; 76( 4): 379- 382. Google Scholar CrossRef Search ADS PubMed  12. Cabral IV, Garcia ED, Sobrinho RNet al.   Increased Capacity for Work and Productivity After Breast Reduction. Aesthet Surg J . 2017; 37( 1): 57- 62. Google Scholar CrossRef Search ADS PubMed  13. Benditte-Klepetko H, Leisser V, Paternostro-Sluga Tet al.   Hypertrophy of the breast: A problem of beauty or health? J Womens Health (Larchmt) . 2007; 16( 7): 1062- 1069. Google Scholar CrossRef Search ADS PubMed  14. Freire M, Neto MS, Garcia EB, Quaresma MR, Ferreira LM. Functional capacity and postural pain outcomes after reduction mammaplasty. Plast Reconstr Surg . 2007; 119( 4): 1149- 56; discussion 1157. Google Scholar CrossRef Search ADS PubMed  15. O’Blenes CA, Delbridge CL, Miller BJ, Pantelis A, Morris SF. Prospective study of outcomes after reduction mammaplasty: long-term follow-up. Plast Reconstr Surg . 2006; 117( 2): 351- 358. Google Scholar CrossRef Search ADS PubMed  16. Panzano EP, Catalán AG, Domínguez RS, Lasfuentes PC, Campayo JG, Sánchez AG. Reduction Mammaplasty Improves Levels of Anxiety, Depression and Body Image Satisfaction in Patients with Symptomatic Macromastia in the Short and Long Term. J Psychosom Obstet Gynaecol . 2017; 11: 1- 11. 17. Sarwer DB, Crerand CE, Magee L. Body dysmorphic disorder in patients who seek appearance-enhancing medical treatments. Oral Maxillofac Surg Clin North Am . 2010; 22( 4): 445- 453. Google Scholar CrossRef Search ADS PubMed  18. Phillips KA, Didie ER, Feusner J, Wilhelm S. Body dysmorphic disorder: treating an underrecognized disorder. Am J Psychiatry . 2008; 165( 9): 1111- 1118. Google Scholar CrossRef Search ADS PubMed  19. Reardon R, Grogan S. Women’s reasons for seeking breast reduction: a qualitative investigation. J Health Psychol . 2011; 16( 1): 31- 41. Google Scholar CrossRef Search ADS PubMed  20. Coriddi M, Nadeau M, Taghizadeh M, Taylor A. Analysis of satisfaction and well-being following breast reduction using a validated survey instrument: the BREAST-Q. Plast Reconstr Surg . 2013; 132( 2): 285- 290. Google Scholar CrossRef Search ADS PubMed  21. Sarwer DB, Bartlett SP, Bucky LPet al.   Bigger Is Not Always Better: Body Image Dissatisfaction in Breast Reduction and Breast Augmentation Patients. Plast Reconstr Surg . 1998; 101( 7): 1956- 61. Google Scholar CrossRef Search ADS PubMed  22. Glatt BS, Sarwer DB, O’Hara DE, Hamori C, Bucky LP, LaRossa D. A retrospective study of changes in physical symptoms and body image after reduction mammaplasty. Plast Reconstr Surg . 1999; 103( 1): 76- 82; discussion 83. Google Scholar CrossRef Search ADS PubMed  23. Rogliani M, Gentile P, Labardi L, Donfrancesco A, Cervelli V. Improvement of physical and psychological symptoms after breast reduction. J Plast Reconstr Aesthet Surg . 2009; 62( 12): 1647- 1649. Google Scholar CrossRef Search ADS PubMed  24. Sacchini V, Luini A, Tana S, Lozza L, Galimberti V, Merson M. Quantitative and qualitative cosmetic evaluation after conservative treatment for breast cancer. Eur J Cancer . 1991; 27( 12): 1395- 400. Google Scholar CrossRef Search ADS PubMed  25. World Health Organization. Global Database on Body Mass Index. http://apps.who.int/bmi/index.jsp. Accessed April 22, 2017. 26. Gust MJ, Smetona JT, Persing JS, Hanwright PJ, Fine NA, Kim JY. The impact of body mass index on reduction mammaplasty: a multicenter analysis of 2492 patients. Aesthet Surg J . 2013; 33( 8): 1140- 1147. Google Scholar CrossRef Search ADS PubMed  27. Rosen JC, Reiter J. Development of the body dysmorphic disorder examination. Behav Res Ther . 1996; 34 ( 9): 755- 766. Google Scholar CrossRef Search ADS PubMed  28. Jorge RT, Sabino Neto M, Natour J, Veiga DF, Jones A, Ferreira LM. Brazilian version of the body dysmorphic disorder examination. Sao Paulo Med J . 2008; 126( 2): 87- 95. Google Scholar CrossRef Search ADS PubMed  29. Brito MJ, Nahas FX, Cordás TAet al.   Prevalence of Body Dysmorphic Disorder Symptoms and Body Weight Concerns in Patients Seeking Abdominoplasty. Aesthet Surg J . 2016; 36( 3): 324- 332. Google Scholar CrossRef Search ADS PubMed  30. Gouveia VV, Santos CA, Gouveia RSV, Santos WS, Pronk SL. Escala de Investimento Corporal (BIS): Evidências de sua Validade Fatorial e Consistência Interna. Aval Psicol . 2008; 7( 1): 57- 66. 31. Moreira H, Silva S, Marques A, Canavarro MC. The Portuguese version of the body image scale (BIS) - psychometric properties in a sample of breast cancer patients. Eur J Oncol Nurs . 2010; 14( 2): 111- 118. Google Scholar CrossRef Search ADS PubMed  32. Ferreira LF, Sabino Neto M, Silva MMA, Resende VCL, Ferreira LM. Brazilian version of the Breast Evaluation Questionnaire: cultural adaptation and validation. Rev Bras Cir Plast . 2013; 28( 2): 270- 5. Google Scholar CrossRef Search ADS   33. de Brito MJ, Nahas FX, Cordás TA, Tavares H, Ferreira LM. Body Dysmorphic Disorder in Patients Seeking Abdominoplasty, Rhinoplasty, and Rhytidectomy. Plast Reconstr Surg . 2016; 137( 2): 462- 471. Google Scholar CrossRef Search ADS PubMed  34. de Brito MJ, Nahas FX, Ortega NRet al.   Support system for decision making in the identification of risk for body dysmorphic disorder: a fuzzy model. Int J Med Inform . 2013; 82( 9): 844- 853. Google Scholar CrossRef Search ADS PubMed  35. Felix GA, de Brito MJ, Nahas FXet al.   Patients with mild to moderate body dysmorphic disorder may benefit from rhinoplasty. J Plast Reconstr Aesthet Surg . 2014; 67( 5): 646- 654. Google Scholar CrossRef Search ADS PubMed  36. Purohit S. Reduction Mammaplasty. Indian J Plast Surg . 2008; 41( Suppl 1): 64- 79. 37. Borkenhagen A, Rohricht F, Schneider W, Brahler E. Changes in Body Image and Heath Relates Quality of Life Following Breast Reduction Surgery in German Macromastia Patients. Ann Plast Surg . 2007; 58: 364- 70. Google Scholar CrossRef Search ADS PubMed  38. Thoma A, Sprague S, Veltri K, Duku E, Furlong W. A prospective study of patients undergoing breast reduction surgery: health-related quality of life and clinical outcomes. Plast Reconstr Surg . 2007; 120( 1): 13- 26. Google Scholar CrossRef Search ADS PubMed  39. Kerrigan CL, Collins ED, Striplin Det al.   The Health Burden of Breast Hypertrophy. Plast Reconst Surg . 2001; 18( 6): 1591- 99. Google Scholar CrossRef Search ADS   40. Collins ED, Kerrigan CL, Kim Met al.   The effectiveness of surgical and nonsurgical interventions in relieving the symptoms of macromastia. Plast Reconstr Surg . 2002; 109( 1): 1556- 66. Google Scholar CrossRef Search ADS PubMed  41. Pruis TA, Janowsky JS. Assessment of body image in younger and older women. J Gen Psychol . 2010; 137( 3): 225- 238. Google Scholar CrossRef Search ADS PubMed  42. Spector JA, Singh SP, Karp NS. Outcomes after breast reduction: does size really matter? Ann Plast Surg . 2008; 60( 5): 505- 509. Google Scholar CrossRef Search ADS PubMed  43. Saariniemi K, Luukkala T, Kuokkanen H. The outcome of reduction mammaplasty is affected more by psychosocial factors than by changes in breast dimensions. Scand J Surg . 2011; 100( 2): 105- 109. Google Scholar CrossRef Search ADS PubMed  44. Gonzalez MA, Glickman LT, Aladegbami B, Simpson RL. Quality of Life after Breast Reduction Surgery: a 10 Year Retrospective Analysis using the Breast Questionnaire. Ann Plast Surg . 2012; 69( 4): 361- 3. Google Scholar CrossRef Search ADS PubMed  45. Shah R, Al-Ajam Y, Stott D, Kang N. Obesity in mammaplasty: a study of complications following breast reduction. J Plast Reconstr Aesthet Surg . 2011; 64( 4): 508- 514. Google Scholar CrossRef Search ADS PubMed  46. Chen CL, Shore AD, Johns R, Clark JM, Manahan M, Makary MA. The impact of obesity on breast surgery complications. Plast Reconstr Surg . 2011; 128( 5): 395e- 402e. Google Scholar CrossRef Search ADS PubMed  47. Cafri G, Yamamiya Y, Brannick M, Thompson K. The influence of Sociocultural Factors on Body Image: A Meta-Analysis. Clin Psychol . 2005; 12( 4): 421- 428. 48. Metcalfe DB, Duggal CS, Gabriel A, Nahabedian MY, Carlson GW, Losken A. Prevalence of Body Dysmorphic Disorder among patients seeking breast reconstruction. Aesthetic Plast Surg . 2014; 34( 45): 733- 737. Google Scholar CrossRef Search ADS   49. Crerand CE, Franklin ME, Sarwer DB. Body dysmorphic disorder and cosmetic surgery. Plast Reconstr Surg . 2006; 118( 7): 167e- 180e. Google Scholar CrossRef Search ADS PubMed  50. Veale D, De Haro L, Lambrou C. Cosmetic rhinoplasty in body dysmorphic disorder. Br J Plast Surg . 2003; 56( 6): 546- 551. Google Scholar CrossRef Search ADS PubMed  51. Veale D, Naismith I, Eshkevari Eet al.   Psychosexual outcome after labiaplasty: a prospective case-comparison study. Int Urogynecol J . 2014; 25( 6): 831- 839. Google Scholar CrossRef Search ADS PubMed  © 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com

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Aesthetic Surgery JournalOxford University Press

Published: Feb 7, 2018

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