Laura C. Nuzzi

The Impact of Macromastia on Adolescents: A Cross-Sectional Study

OBJECTIVE: To determine the physical and psychosocial impact of macromastia on adolescents considering reduction mammaplasty in comparison with healthy adolescents. METHODS: The following surveys were administered to adolescents with macromastia and control subjects, aged 12 to 21 years: Short-Form 36v2, Rosenberg Self-Esteem Scale, Breast-Related Symptoms Questionnaire, and Eating-Attitudes Test-26 (EAT-26). Demographic variables and self-reported breast symptoms were compared between the 2 groups. Linear regression models, unadjusted and adjusted for BMI category (normal weight, overweight, obese), were fit to determine the effect of case status on survey score. Odds ratios for the risk of disordered eating behaviors (EAT-26 score ≥20) in cases versus controls were also determined. RESULTS: Ninety-six subjects with macromastia and 103 control subjects participated in this study. Age was similar between groups, but subjects with macromastia had a higher BMI (P = .02). Adolescents with macromastia had lower Short-Form 36v2 domain, Rosenberg Self-Esteem Scale, and Breast-Related Symptoms Questionnaire scores and higher EAT-26 scores compared with controls. Macromastia was also associated with a higher risk of disordered eating behaviors. In almost all cases, the impact of macromastia was independent of BMI category. CONCLUSIONS: Macromastia has a substantial negative impact on health-related quality of life, self-esteem, physical symptoms, and eating behaviors in adolescents with this condition. These observations were largely independent of BMI category. Health care providers should be aware of these important negative health outcomes that are associated with macromastia and consider early evaluation for adolescents with this condition.

Psychosocial impact of adolescent gynecomastia: a prospective case-control study.

Background: The purpose of this study was to determine the physical and psychosocial impact of gynecomastia and its severity on adolescents seeking treatment as compared with healthy adolescent males. Methods: The following surveys were administered to adolescents with gynecomastia and healthy male controls, aged 12 to 21 years: Short Form-36 Version 2, the Rosenberg Self-Esteem Scale, and the Eating Attitudes Test-26. Demographic variables were compared between the two groups, and controls were administered a short chest symptoms survey. Linear regression models, unadjusted and adjusted for body mass index category, were fit to determine the effect of case status and graded severity of gynecomastia on survey score. Results: Forty-seven patients with gynecomastia and 92 male control subjects participated in this study. There was no difference in mean age between the groups, although patients with gynecomastia had a significantly higher body mass index. Gynecomastia subjects had three lower Short Form-36 domain and Rosenberg Self-Esteem Scale scores independent of body mass index category as compared with controls, although there was no difference in Eating Attitudes Test-26 scores between the groups. Graded gynecomastia severity had no effect on survey scores, all independent of body mass index category. Conclusions: Gynecomastia has a significant negative impact on primarily the psychosocial well-being of affected adolescent patients, specifically in regard to social functioning, mental health, and self-esteem. Psychosocial impact was not affected by graded severity of disease. Health care providers and patients should be aware of the psychosocial impairments associated with gynecomastia and consider early treatment for adolescents suffering from this condition, regardless of severity. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Psychological impact of breast asymmetry on adolescents: a prospective cohort study.

Background: This study measures the impact of adolescent breast asymmetry compared with macromastia and female controls. Methods: The following surveys were given to patients with breast asymmetry, macromastia, and controls aged 12 to 21 years: Short Form Health Survey, Version 2 (Short Form-36), the Rosenberg Self-Esteem Scale, and the Eating Attitudes Test. Demographics were compared, and linear regression models, adjusted for body mass index category and age, were fit to determine the effect of case status on survey score. Results: Fifty-nine adolescents with asymmetry, 142 controls, and 160 macromastia patients participated. After controlling for differences in body mass index category, asymmetry patients scored lower on psychological Short Form-36 domains and the Rosenberg Self-Esteem Scale than controls (p < 0.05), but did not differ in physical health. When compared with macromastia adolescents, asymmetry patients scored significantly better on Short Form-36 physical health domains (p < 0.05), but had similar decrements in emotional functioning, mental health, self-esteem, and eating behaviors/attitudes, after accounting for differences in age. Age and asymmetry type and severity had no effect on survey scores, independent of body mass index category (p > 0.05). Asymmetry patients had a higher mean body mass index percentile than controls (83.36 versus 73.52) but did not differ from that of macromastia patients (83.39). Conclusions: Breast asymmetry may negatively impact the psychological quality of life of adolescents similar to macromastia. Breast asymmetry is not just a cosmetic issue. Providers should be aware of the psychological impairments associated with asymmetry and provide proper support. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Upper extremity anomalies in Pfeiffer syndrome and mutational correlations.

Background: Pfeiffer syndrome is characterized by craniosynostosis and a variety of associated upper and lower extremity anomalies. The authors reviewed presentation and treatment of upper extremity anomalies in a series of genotyped patients with Pfeiffer syndrome. Methods: Medical records of patients with Pfeiffer syndrome seen at the authors’ institution over a 16-year period were reviewed. Data on clinical presentation, genetic testing, and treatment were collected. The upper extremity anomalies were documented using plain radiographs and physical examinations by a multidisciplinary craniofacial team. Results: Of 15 patients identified as having FGFR1- or FGFR2-confirmed Pfeiffer syndrome, 12 (80 percent) presented with upper extremity anomalies, most commonly broad thumbs [n = 10 (83 percent)], radial clinodactyly (thumbs) [n = 7 (58 percent)], and symphalangism [n = 7 each (58 percent)]. All patients with upper extremity anomalies had lower extremity anomalies. Six of the 12 patients (50 percent) with upper extremity findings underwent surgical correction. FGFR1 or FGFR2 genotype did not correlate with upper extremity phenotype. Conclusions: Although broad thumbs are common, patients with Pfeiffer syndrome often present with other upper extremity anomalies that may not require surgical intervention. Genetic and allelic heterogeneity may explain phenotypic variability in these upper extremity anomalies. Characterization of these limb differences should be made by pediatric hand surgeons as part of a craniofacial team. Treatment decisions should be individualized and dictated by the type and severity of clinical presentation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, IV.

Surgical Site Infection After Skin Excisions in Children: Is Field Sterility Sufficient?

Skin excisions are common procedures in children. They may be performed in the clinic using field sterility or the operating room with strict sterile technique. We compared the effect of these locations and the use of antibiotics on the incidence of surgical site infection (SSI) after skin excisions. Patients ages 0–18 years presenting to our department for the excision of lesions from 2006 to 2010 with complete medical records were included in our study. Records were reviewed for demographic characteristics, presentation, perioperative conditions, and postoperative SSI and other wound complications. Analyses were performed to estimate the costs associated with sterility technique and perioperative antibiotic use. We identified 700 patients with a mean age of 9.1 years. Of 872 lesions excised, 0.3% resulted in SSI and 1.8% had other wound complications. The incidence of SSI did not vary according to sterility technique, antibiotic usage, surgeon, age, or lesion size, type, or location. The equipment costs to excise a lesion in the operating room were 200% greater than in the clinic. The incidence of SSI after excision of benign lesions in children did not differ between those performed using clinic field sterility and those using the standard aseptic sterile technique in the operating room. A considerable cost savings could be realized by adopting field sterility for simple excisions performed in the operating room and avoiding routine perioperative antibiotics in pediatric skin excisions.

Weight Changes After Reduction Mammaplasty in Adolescents

PURPOSE The ability to exercise more easily and weight loss are often cited benefits of reduction mammaplasty. However, measured weight outcomes after this common procedure are lacking. The purpose of this study was to measure body mass index (BMI) changes in an otherwise healthy adolescent sample after bilateral breast reduction. METHODS We retrospectively reviewed the records of patients aged 12-21 years who underwent reduction mammaplasty at our institution between 2007 and 2013, with a minimum postoperative follow-up time of 1 year. Charts were reviewed for preoperative and postoperative height and weight, amount of breast tissue resected, and medical comorbidities. No formal nutritional support or weight loss program was instituted before or after surgery. RESULTS Eighty patients meeting eligibility criteria were identified. The mean follow-up time was 2.0 ± 1.0 years. Mean postoperative BMI did not differ significantly from mean preoperative BMI (27.8 ± 7.1 kg/m(2) vs. 27.3 ± 6.4 kg/m(2)). However, among overweight and obese patients, a significant gain in preoperative to postoperative BMI was observed, on average (p = .019). Twelve (22.2%) of these patients increased their BMI by at least 10% after reduction mammaplasty. Although approximately one third (37%) of overweight/obese patients decreased their BMI, only 5.6% decreased BMI by at least 10%. CONCLUSIONS We found no significant difference between mean preoperative and postoperative BMI among patients who underwent reduction mammaplasty. Our results suggest that although reduction mammaplasty may facilitate exercise and help some patients lose weight, meaningful postoperative weight loss without additional support is rare.

Intermediate and Long-term Outcomes of Giant Fibroadenoma Excision in Adolescent and Young Adult Patients

Giant fibroadenomas (5 cm or greater) are benign breast masses that often present in adolescence and require surgical excision. Long‐term outcomes, recurrence rates, and the need for additional reconstructive surgery in this population are unknown. Patients aged 11–25 years whose pathology reports indicated the presence of a giant fibroadenoma were eligible for this study. Medical records were reviewed for presentation, treatment, and outcomes. A subset of patients completed an investigator‐designed long‐term outcome survey to measure additional outcomes and the desire or need for subsequent reconstructive surgery. Forty‐six patients with at least one giant fibroadenoma (mean size 7.4 ± 2.8 cm) were identified. Most patients underwent excision with a periaroeolar incision (n = 31), and an enucleation technique (n = 41), and four patients underwent immediate breast reconstruction. Thirty‐three patients had complete medical records with a mean follow‐up time of 2.2 ± 4.1 years and no complaints of asymmetry, additional breast deformities, or reconstructive surgery procedures documented. In addition, nine patients completed the investigator‐designed survey with a mean follow‐up time of 10.1 ± 8.7 years (range 1.5–27.0). Three of these patients reported postoperative breast asymmetry and the desire to pursue reconstructive surgery. Aesthetic outcomes of giant fibroadenoma excision may be satisfactory for many patients without immediate reconstruction, but for others, the need for reconstructive surgery may arise during development. Providers should address this potential need prior to discussing treatment options and during postoperative follow‐up. Caution should be exercised before recommending immediate reconstruction.

Abstract: Surgical Treatment of Breast Asymmetry Improves Quality of Life in Adolescents and Young Women

RESULTS: The mean ages of breast subjects (n=42) at surgery and controls (n=103) at baseline were 17.4 and 16.7 years, respectively. All asymmetry forms were included (most frequent size difference was two cups; mean volume difference was 213 mL). At baseline, asymmetry subjects performed significantly worse than controls in the role-emotional SF-36 domain and on the RSES and EAT-26. Postoperatively asymmetry subjects experienced significant improvements in three SF-36 domains (social functioning, role emotional, mental health) and on the EAT-26. These results largely did not vary by age, BMI category, and asymmetry severity. Postoperative asymmetry patients performed equally to controls in all eight SF-36 domains, and on the RSES and EAT-26.

Abstract 115: Effect of Surgical Complications on Health-Related Quality of Life Outcomes in Adolescents and Young Women Following Reduction Mammaplasty

METHODS: We retrospectively reviewed 542 breast reconstructions, performed by two surgeons (SST,NTH) at one tertiary care academic hospital from January 2012 to February 2016. Patients choosing implants and completing reconstruction (n=269) were split into 4 groups based on GCR status and combined gynecologic procedures (GYN) status: GCR+, GYN+ (Group1,n=26); GCR+, GYN(Group2,n=41); GCR-, GYN+ (Group3,n=5); GCR-, GYN(Group4,n=197). GCR included mutations in BRCA, CHEK2, PALB2, Li-Fraumeni Syndrome, and others. Oneway ANOVA (df between groups = 3, df within groups = 265) and Tukey HSD was performed to compare differences in the percentages of patients with necrosis requiring surgery, infection requiring IV antibiotics, seroma, and device exchange.

Central Coalition Osteotomy of Phalangeal Synostoses in the Management of the Type III Apert Hand

PURPOSE We report a technique in the management of the type III Apert hand. The proposed approach facilitates the creation of a 5-fingered hand in 3 stages. METHODS We reviewed records of patients with Apert syndrome and type III hands surgically treated at our institution from 1995 through 2014. In all cases, syndactyly release was performed in 3 stages with prioritization of the border digits. In addition, limited retrograde, axial osteotomies between the phalangeal segments of the conjoined index, middle, and ring fingers were performed during the first stage. Medical records were reviewed for demographics, clinical presentation, operative findings, and postoperative outcomes. RESULTS Twelve pediatric patients with type III hands underwent syndactyly release. Median patient age was 10.0, 15.8, and 29.6 months at operative stages 1, 2, and 3, respectively. A thumb and 4 fingers were achieved for all but 1 hand. The median duration of hospital stay was 2 days for each stage. No infections or major complications were observed. CONCLUSIONS We demonstrate this method as a safe and effective means of creating 5 digits in the Apert patient with type III hands. Our opinion is that the additional aesthetic and functional gains offset the requirement of a 3-stage approach. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.