Breast procedures—reconstructive and aesthetic—always seem to be controversial topics. PSP reviews four studies released at the American Society of Plastic Surgeons (ASPS) meeting in San Francisco last month.

Obesity and Breast Reconstruction
A study authored by Elisabeth Beahm, MD, associate professor at MD Anderson Cancer Center, Houston, examined safety issues for obese women considering breast reconstruction following mastectomy. The study concluded that these women should delay the procedure until they achieve a healthier body weight.

“We found that significantly obese patients, those having a body mass index [BMI] of 35 or higher, had a higher risk for complications,” Beahm said. “Our experience suggests that in many cases, it may be more prudent to delay breast reconstruction until the patient has lost weight.”

According to the study, patients with a BMI greater than 35 exhibited increased complication rates for all types of breast reconstruction—from implants to flaps. The complication rate approached 100% for morbidly obese patients with a BMI of more than 40.

Beahm said the most frequent complications for obese patients were fluid collections and infection at both the reconstructive site and the flap-donor site. When the flap was harvested from the abdominal area, weakness and deformity of the abdominal wall, such as hernia and bulge, was much more common than in normal-weight patients.

Lumpectomy Dissatisfaction
Howard Wang, MD, of San Antonio discussed why patients are unhappy with the aesthetic outcome of lumpectomy. According to a study he coauthored, women with breast cancer often undergo lumpectomy and radiation to save their breasts and avoid the need for additional reconstructive surgery. However, approximately one third of all patients who undergo breast-conservation therapy are unhappy with how their breasts look afterwards, and many would consider reconstruction.

Wang reported that 28% of breast-cancer patients who had a lumpectomy said they were dissatisfied with its aesthetic result. Of those patients, 46% said their physical appearance was worse or much worse after the surgery and that they were considering reconstruction. Only 9% of patients who were satisfied with the outcome would consider reconstruction if it were offered.

The study also found that approximately 26% of patients who had a lumpectomy were unhappy with their physical appearance afterward but had an improved sense of body image. The study’s authors believe this disparity occurred because many patients felt relieved to be free from the cancer, leading them to feel better about their bodies even though they were not happy with how their breasts looked.

Breast Asymmetry and Self-Esteem
Breast surgery can increase quality of life and self-esteem for patients with significant asymmetry, according to another study presented at the ASPS meeting.

 “Most women do not understand how common breast asymmetry is and are surprised when I show them pictures in my books of patients with one or two different cup sizes in each breast,” says Andrew T. Cohen, MD, FACS, of Los Angeles. “Many younger women come to me to try and achieve symmetry and are surprised when I show them how common it is. It affects their self-esteem and ability to wear certain clothing and bathing suits. In order to achieve symmetry, it can take one operation; or sometimes with significant asymmetry, it must be done in a staged two-operation approach.”

Breast asymmetry occurs when breasts are different sizes, shapes, or both. Even if both breasts are the same size, they appear asymmetric if one droops and the other doesn’t.

In the study, the authors measured how breast-asymmetry surgery impacted quality of life and self-esteem in 35 patients. They found that 6 months after undergoing surgery, all of the patients’ vitality, mental health, and self-esteem significantly improved.

Breast-Reduction Coverage Denied
Oversized breasts can be a burden on women, causing them pain and restricting them from performing daily activities. Despite scientific studies on the medical necessity of breast reduction, most insurance companies deny thousands of women the procedure each year because of rigid, unfounded coverage requirements.

According to George John Bitar, MD, who practices in northern Virginia, it is easy for insurance companies to deny a breast-reduction claim because they can always justify the decision by labeling the reduction as an aesthetic procedure.

“Breast-reduction requests, with photos, should be reviewed by a board-certified plastic surgeon experienced in breast-reduction surgery, whose authority is granted by both the insurance company and the ASPS to guarantee impartiality,” Bitar says. “That particular surgeon should make a clinical decision, on a case-by-case basis, whether to accept or deny a claim, rather than to abide by arbitrary criteria that make it difficult and frustrating for legitimate patients to be covered by their insurance company.

“The amount of tissue removed from any breast is not a magic number. It varies between one insurance company to the other, because in reality, everyone is different, and no one knows what is the right amount. It should be viewed in the context of a patient’s height, weight, anatomy, symptoms, and surgical technique.”

A study coauthored by Michael Wheatley, MD, of Portland, Ore reviewed the breast-reduction policies of 87 insurance companies. Despite medical findings to the contrary, 85 companies require a minimum amount of tissue to be removed to cover the procedure, and 49 require a minimum amount to be removed independent of patient height and weight.

The amount of tissue removed, body weight, obesity level, or cup size do not affect the benefits that patients receive from breast reduction, according to published studies.Many insurance companies require that patients exhibit all of the following symptoms to receive coverage for breast reduction: back, neck, shoulder, and arm pain; rashes; bra-strap grooves; and numbness in the upper torso.