Functional Capacity and Postural Pain Outcomes after ...

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Functional Capacity and Postural Pain Outcomes after Reduction Mammaplasty

Miguel Sabino Neto PhD, Marcia Freire PhD , Elvio Bueno Garcia PhD , Lydia Masako Ferreira PhD.

Division of Plastic Surgery, Department of Surgery, Federal University of São Paulo, Rua Napoleão de Barros, 715, 4o. andar Vila Clementino, São Paulo, SP CEP 04024-002, Brasil.

1. INTRODUCTION :FOGED (1953) (1) defined mammary hypertrophy as being an increase of the mammary gland beyond the physiological limits, except for increases caused by accidents, tumors, hemorrhages, inflammatory processes and pregnancy. Several symptoms can be traced to mammary hypertrophy, the most common being: pain in the neck, shoulders and low back regions. Difficulty in dressing, discomfort during sleep (2-4), marks on the shoulders and below the breasts, as well as, skin lesions are among other complaints reported by patients.

Whatever the surgical technique used, the objective is a result both esthetic and functional that improves the social, physical and emotional impact which mammary hypertrophy causes in the patient’s life. Although breast reduction surgery is considered common in medicine (5), the benefits to the patients have not been quantified nor standardized objectively (6.

Functional capacity goes beyond physical performance; it relates to how the patients carry out their daily activities. Functional capacity reflects how well the patient absorbs the impact of the disease in her daily routine; it is individual and determined by a complex interaction of clinical variables and psychosocial factors. Functional capacity has been used as one of the parameters for evaluation of health related quality of life. The “Stanford Health Assessment Questionnaire” (HAQ-20) is an instrument that can be self administered, comprising eight components that evaluate distinct aspects of the daily life of the patient (10). The Visual Analog Scale (VAS) is a simple and quick method for evaluating pain intensity and has already been used to detect alterations in the postoperative phase (11). It is a 10 cm line where the left extremity represents no pain (Zero) and the right extremity represents unbearable pain. After systematic review of literature, reduction mammaplasty appears to improve pain and functional capacity, but no scientific evidence was found to confirm it. The present study propose to evaluate the impact of reduction mammaplasty on functional capacity and pain in the neck, shoulders and low back regions of patients with mammary hyperthrophy.

2. METHODS :One hundred patients with mammary hypertrophy were consecutively selected from the Plastic Surgery Outpatient Clinic of UNIFESP-EPM, São Paulo. The patients were invited to participate in the prospective study to evaluate functional capacity and pain (neck, shoulders and low back regions) after reduction mammaplasty. For patients' selection the following criteria were considered. Inclusion criteria: patient between 18 and 55 years of age; diagnosis of mammary hypertrophy; symptoms related to the size of the breasts. Exclusion criteria: obesity body mass index (BMI) equal or superior to 30 Kg/m2 (13), unilateral mammary hypertrophy; mammary hypertrophy with severe asymmetry; smokers; patient with acute diseases, either chronic or recurring; previous mammary surgical procedures; illiterates; and, finally, patients who had breast fed less than one year ago.

Preoperative (baseline) evaluation (Phase 1): The patients were then randomly allocated by lottery into two groups. Group A was composed of 50 patients who were submitted to mammaplasty reduction immediately, while group B (control group), also composed of 50 patients, went onto a waiting list to be submitted to surgery 6 months after the start of the study (Reviewer 2: no ethical problems and approved by ethical revision of São Paulo University). At phase 1, all patients were submitted to an interview and an evaluation, by a single researcher (a plastic surgeon), following the same sequence: collection of social and demographic data; evaluation of symptoms related to mammary hypertrophy; measurement and classification of mammary hypertrophy; photographic documentation; and, finally, completion of two self-administered questionnaires: “Stanford Health Assessment Questionnaire”, Brazilian version, to measure functional capacity (HAQ-20) and visual analog scale (VAS) to measure neck, shoulders and low back pain. Group A patients answered the questionnaires seven days before the surgical procedure.

Six month Postoperative evaluation (Phase 2): The patients of Groups A and B were appraised in the plastic surgery outpatient clinic using the same measurement instruments as those for phase 1 (HAQ-20 and VAS). Early and late postoperative complications were analyzed for group A, as well as the histopathological test results. Group B patients were evaluated six months after the first one and the results were compared to those of group A. After completion the study patients of group B were all submitted to surgery.

Instruments for the measurement of Functional Capacity and pain: To evaluate functional capacity, the Stanford Health Assessment Questionnaire (HAQ-20) was used. The version applied was the one translated into the Portuguese language, adapted for Brazilian culture and validated (19. Intensity of neck, shoulders and low back pain was measured by using the Visual Analog Scale (VAS).

3. RESULTS :The demographic data of the 100 patients in Phase 1 are represented in Table I. The comparative analysis between the two groups in relation to socio-demographic data showed no statistical diference between groups A and B. The clinical data in relation to the body mass index, degree of hypertrophy and Sacchini classification (20) as to breast size are presented in Table II. The comparative analysis between the two groups in relation to clinical data showed no statistical diference between them. The surgically ressectioned tissue as sent for weighing, as shown in Table III.

Six months after the first evaluation we had a complete follow up of 92% (46/50 in both groups: patients submitted to reduction mammaplasty (Group A) and control patients (group B). Four patients who had undergone reduction mammaplasty followed through until the third postoperative month, three patients were not located six months after surgery and one of the patients became pregnant two months after surgery. In Phase 2 of the study, among the control group of patients, one was pregnant and another three had been operated on in another Plastic surgery unknown clinic, and for these reasons were not called for the second evaluation. Evaluation of Postural Pain are showed in tables IV, V and VI.

When we evaluate the percentage of patients who reported symptoms of pain in any one of the three regions evaluated, we note that this percentage dropped in the postoperative period, but the complete absence of symptoms occurred for 48% of them, with the remainder still having some complaint, although to a lesser clinical importance(Table VII). In the evaluation after six months of reduction mammaplasty, three cases, all aged over 40 years, did not obtain any improvement in lumbar pain, remaining with an index of 10. Nineteen patients from group A presented complaint of pain in two or more regions, even after surgery. Evaluation of functional Capacity is demonstrated in table VIII. No patient, whether from Group A or B, stated that she was not able of carrying out a determined task or activity evaluated by the eight components of HAQ-20, as much in Phase 1 as in Phase 2 of the study. The analysis of the eight components of the HAQ-20 questionnaire for the patients of groups A and B, in the two phases of the project, is demonstrated in Table IX. Using Pearson correlation coefficient table X shows the correlation between the total ressectioned weight of the breasts with VAS mean scores obtained when pain was measured in the neck, shoulders and low back and HAQ-20 mean scores. We did not detect correlation with the variables.

4. DISCUSSION:The evaluation of the functional capacity and intensity of the pain using instruments whose measure properties were already tested, it checks larger credibility to the studies accomplished previously on hipertrophy breast and reduction mammaplasty (22,5,23). These studies contributed to the knowledge of the symptoms that accompany the mammary hipertrophy, however they were accomplished in retrospect and with instruments no validated. The patients' selection in our research, had as objective forms a group with similar characteristics, where the alterations in the studied aspects were credited to the surgical procedure. The size of our sample is similar to the prospective studies presented in the specialized literature (24,25,11) and it was shown enough for us to obtain, through statistical analyses, results comparable to the of other studies. A systematic review of the literature, in the period from 1985 to 1999, CHADBOURNE et al. (2001) (7) concluded that there were positive alterations in the functional capacity and pain intensity after reduction mammaplasty, however it was not possible to quantify these alterations. Using the same analysis methodology JONES & BAIN (2001) (8) related 17 publications that obeyed revision criteria, but they were not appropriate for inclusion in the metanalises. The studied aspects (functional capacity and pain) can suffer alterations for diseases ignored by the own patient, as rheumatic diseases, orthopedical or neurological. To avoid bias the present study was designed with control group.

The components of HAQ-20 were separately evaluated. It was observed after six months of the surgery an improvement in the following aspects: dress, get up, walk, take shower, reach objects and prehension maneuvers. It was observed no alterations in the action of feeding. Dressing became more pleased, because besides acquiring larger easiness of movements with the superior members, the patients told that to find appropriate clothes became easier. BROWN, HILL, KHAN, (2000) (28) observed the same in their study. About 38% of the patients in group A had difficulties in dressing, especially for related maneuvers to lift the arms or to lower to tie the shoes. This number fell for 4% in the postoperative stage.

I square fellow creature observed in the related activities to reach objects above the head's level or to lower in the attempt of catching objects in the ground. Even after the mammaplasty still about 20% of the patients told to have difficulties. When, however, we analyzed the aspect to walk and to take a shower, we noticed improvement in almost all patients.

In the general evaluation of the functional capacity, we noticed that the main difficulties are related to the action of to get up and to lower, independent of the tasks (domestic, social or professionals). The patients told that the damage in those maneuvers is related to the backaches.

CHAO et al. (2002) (11) accomplished a study with 50 patient with mammary hipertrophy, where the medium index of pain was of six; that study didn't accomplish a different research for each attacked area (neck, shoulders and lumbar), however it evaluated the tension in some of the related muscles the sustentation of the spine and noticed that it can have alterations in this musculature after the surgery, improving like this the posture and the pain intensity.

We didn't observe direct correlations between larger tissue excised and it gets better of the pain intensity and functional capacity, as well as reported by CHAO et al. (2002) (11). This finding corroborates the studies of MILLER et al. (1995) (32) where they were not found models to foresee the degree of improvement of the symptomatology in agreement with the amount breast tissue excised. However we found authors that after studies with patients with mammary hipertrophy found relationship between intensity of the pain and size of the breast (33). FREIRE (2004) (30) using generic questionnaire for evaluation of the quality of life (SF-36) detected a tendency of inverse correlation between tissue excised and functional capacity and positive correlation between tissue excised and preoperative pain, what didn't happen with other authors, that used the same evaluation method (24). These disagreements take us to contemplate on the validity of generic questionnaires in evaluating specific aspects of the mammary hipertrophy. The use of the VAS for each attacked area, just relating the symptoms, it demonstrates our attempt in lessening these doubts as the relationship between weight of the preoperative breast and relief of the symptomatology.

The results of present study developed scientific evidence of the benefits of reduction mammaplasty in the functional capacity and postural pain in patients with hypertrophy breasts.


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Table I – Demographic Data (Phase 1)

| | |Group A (n=50) |Group B (n=50) | p |

|Age |Variation |17-55 |17-55 |0.7 |

| |m(DP) |31.6(11) |32.3 (10) | |

|Race |White |31 (62%) |22 (44%) |0.07 |

| |Non white |19 (38%) |28 (56%) | |

|Educational level |Elementary |16 (32%) |19 (38%) |0.9 |

| |Highschool |30 (60%) |27 (54%) | |

| |College |4 (8%) |4 (8%) | |

|Marital State |Married |21 (42%) |24 (48%) |0.87 |

| |Single |16 (52%) |24 (48%) | |

| |Widow |01 (2%) |0 | |

| |Divorced |02 (4%) |02 (4) | |

| | | | | |

Table II – Preoperative Clinical Evaluation (Phase 1)

| | |Group A (n=50) |Group B (n=50) | p |

|BMI (Kg/m²) |Variation |21.35 – 29.90 |20.00 – 29.90 |0.59 |

| |m(SD) |25.43 (2.06) |25.69 (2.71) | |

|Mammary |2nd. |36 (72%) |35 (70%) |0.82 |

|Hypertrophy |3rd. |14 (28%) |15 (30%) | |

|(Franco & Rebello) | | | | |

|Sacchini |Right breast |11.00 – 20.00 |11.00 – 19.50 |0.41 |

|Measurement |m (SD) |15.32 (1.98) |15.64 (2.00) | |

|(nipple-furrow +sternal- |Left breast |11.75 – 21 |11.00 – 19.50 |0.34 |

|nipple)/2 |m (SD) |15.28 (1.98) |15,65 (1.88) | |

|< 9 small | | | | |

|9 – 11 medium | | | | |

|> 11 large | | | | |

Table III – Weight of ressectioned breasts: evaluation of the 50 surgical procedures carried out

| | |Right Breast (n=50) |Left Breast (n=50) | Total |

|Total ressectioned weight|Variation |155g – 1625g |135g – 1445g |290g –307g |

| |m |523.93g |528.26g |1052.19g |

Table IV - Analysis of neck pain intensity measured by the visual analog scale in the two phases of the study for both groups.

| |Neck VAS | | |

| |Phase I |Phase 2 | p |

| |Mean (SD) |Mean (SD) | |

|Reduction mammaplasty (46/50) | 5.2 (2.9) |0.9 (1.3) | ................

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