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Psychosocial outcome and patient satisfaction following breast reduction surgery
British Journal of Plastic Surgery (1999), 52, 448–452 © 1999 The British Association of Plastic Surgeons
Psychosocial outcome and patient satisfaction following breast reduction surgery F. Souza Faria, E. Guthrie, E. Bradbury and A. N. Brain Department of Psychiatry, University of Manchester, Manchester Royal Infirmary, Manchester, UK SUMMARY. There is an increasing awareness that psychosocial outcome and health status are important outcomes following breast reduction surgery. In this study, patients awaiting breast reduction surgery completed detailed and comprehensive psychosocial assessments before and after surgery. Of 33 patients who completed the preoperative assessment, 20 patients were operated on and 19 were reassessed 4 months post-surgery. Patients expressed high levels of satisfaction with specific and overall results of surgery. Scores for anxiety, depression, body image and body satisfaction improved significantly using specific questionnaires. Patients also reported significant improvements on five out of eight subscales on the Short Form 36 health status questionnaire. This study provides further evidence for overall improvement in health status and psychological functioning in patients undergoing breast reduction surgery and supports the provision of this service by the NHS. Keywords: breast reduction, outcome, SF36, body image.
post-surgery assessment. In a similar study,3 patients were assessed on the day prior to surgery and at 3 and 6 months following surgery using the SF36 and Rosenberg’s self-esteem scales. The researchers initially assessed 110 patients and had a higher response rate of 82% at 3 months and 76% at 6 months, respectively. Significant improvements were reported in selfesteem and on six dimensions on the SF36 at 3 months, and on five dimensions at 6 months. Ninety six per cent of patients were satisfied with their surgery and there was a minor complication rate of 34%. However, neither of these studies included detailed psychological testing. Body image and body satisfaction are abstract but crucial issues in patients undergoing plastic surgery. The former refers to how an individual views his or her body in the mind’s eye and the latter alludes to subjective satisfaction with one’s body. The two are intimately related and to date have not been systematically investigated in patients undergoing breast reduction. The researchers decided to use two questionnaires; one designed to measure body satisfaction in patients suffering from eating disorders (Body Satisfaction Scale),5 and the other designed for use in patients undergoing reconstructive surgery for carcinoma of the breast (Body Image Scale).6 We wished to record patients’ perceptions of their breasts following surgery, and their perception of other parts of their body. It is possible that some patients requesting breast reduction surgery have a deep dissatisfaction with many parts of their body, not only their breasts. This negative body image may be related to low selfesteem and a general belief that they are overweight. In such patients, the focus of dissatisfaction with their bodies may shift following surgery to another part of their body (e.g. abdomen). Questionnaires which focus on the breast may miss this shift of focus and imply a good outcome, when in reality the patient has become
There has been considerable improvement in surgical techniques of breast reduction in the last three decades. However, research on psychosocial outcome, patient satisfaction and changes in quality of life have until recently been relatively neglected.1 There are at least two reasons why it is imperative that such research is carried out. The first is increasing public awareness of plastic surgery and the legitimate demand by patients for more information that is relevant to them. The second reason is the limitation of finances in a public health service and the need to make ‘evidence based’ decisions about the allocation of resources. Some health authorities have already put restrictions on breast reduction surgery and if the procedure is to remain available in the NHS there is a need to demonstrate not only a favourable physical outcome but also an overall improvement in quality of life and psychosocial functioning. In an early study1 an overall satisfaction rate of 80.6% was noted in 31 patients at 1 month postoperative follow-up. However, no standardised measures were used to measure health status and general wellbeing. Recently, two studies2,3 have recorded not only patient satisfaction but also changes in health status following surgery. Klassen et al2 in a large postal survey used three standardised measures to assess health status before surgery and 6 months after surgery. These were: the Short Form 36 health survey questionnaire which measures eight dimensions of health related quality of life, the General Health Questionnaire (measures psychological wellbeing) and Rosenberg’s self-esteem scale. Out of a total sample of 166, 128 (77%) were assessed preoperatively of whom 85 were operated during the study period and 58 (68%) reassessed after surgery. Significant improvements were reported on all three questionnaires including the eight subscales on the SF36. However, many were lost to follow-up with only 68% of patients completing the 448
Outcome of breast reduction
preoccupied with a different part of her body. It would be important to record whether similar changes were noted in the two relatively new scales. In addition, standardised measures of anxiety and depression (Hospital Anxiety and Depression Scale, HADS) and health status (SF36) were used to assess outcome following breast reduction surgery. Specifically, we wished to answer the following questions. Do patients who undergo breast reduction surgery show an improvement in psychological functioning and health status following surgery? Is there any evidence that patients’ previous dissatisfaction with their breasts is transferred on to a different part of their body after surgery? Patients and methods The study was conducted at the Department of Plastic Surgery, Withington Hospital between January 1995 and February 1996. All patients on the waiting list for three consultants who fulfilled the study criteria were approached. Patients below the age of 16 years or above 65 years were excluded. Patients living outside the Greater Manchester area were also excluded. Patients were initially sent a letter explaining the study, which was followed by a telephone call and were given the choice of taking part in the study by post or by person. All patients who took part in the study answered a semi-structured questionnaire which included the following: demographic details, bust size (e.g. 36DD), physical, psychological and social problems due to large breast size and changes hoped for following surgery. Patients were also asked to complete two well recognised psychological self-report questionnaires and two more specialised questionnaires. These were: 1. The Hospital Anxiety and Depression Scale (HADS) which is a widely used self-report scale of anxiety and depression, and was designed for use in patients with physical illness. Hence, items related to both physical and emotional disorder are excluded. It includes 14 items, 7 relating to anxiety and the remaining to depression resulting in one score for anxiety HAD(A) and another for depression HAD(D). A score of 8 or more on either the anxiety or the depression scale is the usual cut-off score for ‘caseness’.4 Patients scoring above the cut-off are deemed likely to have possible psychological disturbance of a clinically relevant nature. 2. The Body Satisfaction Scale (BSS) is a simple self-report questionnaire which was devised to record body image disturbances in subjects with eating disorders. The scale consists of a list of 16 parts; half involving the head (head, face, jaw, teeth, nose, mouth, eyes and ears) and the other half involving the body (shoulders, neck, breasts, abdomen, arms, hands, legs and feet). Subjects are asked to rate satisfaction/dissatisfaction with each of these body parts on a seven point scale.5 3. The Body Image Questionnaire (BIQ) is an eight item questionnaire devised to assess body image disturbance in patients undergoing mastectomy.
449
Patients are asked to rate their feelings regarding their appearance in the last week, and changes that may have occurred as a result of surgery, on a four point scale. Five items are related to general appearance and three specifically to the breast. These three items were modified for the purposes of this study and the word ‘scar’ was changed to ‘breast size’, i.e. ‘do you feel less eminine’/‘physically attractive’/‘sexually attractive due to your breast size’. The other five items relate to self-consciousness regarding appearance, dissatisfaction with one’s body, dissatisfaction when dressed, difficulty looking at self when naked and avoiding people because of the way one feels about one’s appearance.6 4. Short Form 36 (SF36) which is a well recognised measure of health status.7 It has eight subscales: physical function, role limitation (physical), role limitation (mental), social function, mental function, energy, pain and health perception. Scoring is out of 100 and a high score indicates good function.8 Approximately 4 months following surgery patients were contacted again and the above questionnaires were readministered by post. They were also asked to complete a postoperative satisfaction questionnaire including how pleased they were with shape, size and symmetry of their breast, nipple and scar as well as severity of postoperative pain (at 48 h and at followup; scale 0–10), any complications and overall satisfaction with surgery. All the assessments were conducted by FSF, a senior psychiatric trainee, who was independent of the plastic surgery department. The results were analysed using the Statistical Package for Social Sciences (SPSS). Continuous, normally distributed, data were compared using paired ttests (Hospital Anxiety and Depression Questionnaire and Body Image Questionnaire). Some of the data were not normally distributed, so the Wilcoxon Matched Pairs Signed-Rank Test was used for pre- and postoperative comparisons (SF36 and Body Satisfaction Questionnaire). Most of the results are presented in the form of means and standard errors of the mean (SEMs). Data which were not normally distributed are presented in the form of median and interquartile ranges (IQRs).
Observations and results Thirty-three out of 52 patients on the waiting list were assessed preoperatively. Of those remaining, 3 declined to take part in the study and 16 patients did not respond to a written invitation to attend an interview and were not contactable on the telephone. Ten patients were interviewed and the remaining completed the study by post. The non-attenders were similar in demographic characteristics to those who took part in the study but detailed psychological comparison between participants and non-participants could not be undertaken. Twenty out of 33 participants were operated upon during the duration of the study and
450
British Journal of Plastic Surgery
Table 1 Psychological symptoms Preoperative Variable HAD A HAD D Body Image
Postoperative
No. of pairs
Mean
SEM
Mean
SEM
P* (2 tail sig.)
19 19 19
7.6 5.6 17.2
0.9 0.8 1.3
4.3 1.0 3.7
0.7 0.2 0.9
0.009 <0.001 <0.001
*Paired t-test; SEM = standard error of the mean.
Table 2 Short Form 36 Preoperative Variable Physical fun Role limitation (physical) Role limitation (mental) Mental health Pain Health perception Social fun Energy and vitality
Postoperative
No. of pairs
Mean
SEM
Mean
SEM
P (2 tail sig.)
19 19 19 18 18 19 18 18
77.4 68.4 70.2 60.4 54.3 69.0 75.9 48.9
4.1 9.1 8.8 3.7 5.3 5.1 4.8 4.9
89.5 80.3 93.0 77.3 67.3 76.8 85.2 66.7
3.7 8.7 5.5 3.2 6.7 5.2 5.8 4.2
0.006 0.27 0.044 0.001 0.053 0.027 0.18 0.007
SEM = standard error of the mean.
100 90 80 70 60 50 40 30 20 10 0
Pre-operative Post-operative
vitality
Energy and
functioning
Social
perceptions
Health
Pain
health
Mental
mental
Role –
physical
Normative data
Role –
Mean and SEM
Patients scored significantly higher on five out of eight subscales of the SF36 Questionnaire following surgery indicating improvement (Table 2). These subscales were: physical function, role limitation (mental),
functioning
The mean score on the Body Image Questionnaire (BIQ) also improved significantly using paired t-tests (Table 1). Body satisfaction scores (Body Satisfaction Scale) were not normally distributed and hence
Health status SF36
Physical
Body image and satisfaction
analysed using Wilcoxon Matched Pairs Signed Rank Test and reported as median and interquartile range scores. Patients were significantly more satisfied with their bodies following surgery: preoperative median = 11, IQR (7–18); postoperative 6, (3–9); P = 0.005. The data were further analysed comparing remaining body parts excluding breasts. Patients’ scores for dissatisfaction were again significantly lower following surgery: preoperative 8, (4–15); postoperative 6, (3–9); P = 0.049.
SF-36 score
three patients aged 16, 21 and 22 years changed their mind about surgery. With the exception of one who moved away all the remaining 19 (95%) patients were assessed postoperatively. The mean duration of follow-up was 4 months (range 1–10). All 19 patients were satisfied with both their new breast shape and size and none felt their breasts were over or under reduced. Seventeen patients felt that their reduced breasts were symmetrical, although one patient was unsatisfied and another unsure. Eighteen patients were pleased with both the shape and size of their nipples although one was unsure. All 19 patients were satisfied with position of the scar, although 5 were unhappy with its healing. The mean score for pain was 5.6 out of 10 (SE = 0.6) at 48 h after surgery and 0.6 out of 10 (SE = 0.2) 4 months after surgery. Twelve out of 19 developed minor complications, mainly wound infection. Eight felt breast sensation was unaffected, six felt their breasts were less sensitive and five felt they were more sensitive. Sixteen were very satisfied with the outcome of surgery, three moderately satisfied and none were unsatisfied or unsure. Scores for anxiety and depression on the Hospital Anxiety and Depression Scale improved significantly following surgery (Table 1). The number of patients scoring above the cut-off point for caseness (i.e. possible psychiatric disorder) on the HADS for anxiety decreased from 6 to 4 following surgery and for depression from 4 to 0.
Figure 1—SF36 comparison of preoperative, postoperative and general female population from a large community sample in the Oxford Health Region.8
Outcome of breast reduction
mental health, health perception and energy and vitality. The improvement for pain was not quite significant (P = 0.053). The pre- and postoperative scores were further compared to normative data for the general female population (Fig. 1) which were obtained from a large community sample in the Oxford Health Region.8 The preoperative scores were significantly below the scores for the normal population on six out of eight subscales of the SF36, but following surgery the patients’ scores had improved to either normal or above normal scores, except for the pain subscale (Fig. 1). This could be explained by residual pain in some patients following recent surgery. Discussion This study confirms that high levels of patient satisfaction, decreased psychological symptomatology and improved health status follow breast reduction surgery. The high rates of satisfaction reported by the women post-surgery with the shape, size and symmetry of their breasts are similar to those reported in other studies of breast reduction surgery.1,3 Improvements in anxiety and depression scores on the HADS in the present study are comparable to the improvement in psychological wellbeing noted in a previous study, using the General Health Questionnaire.2 It is important to note that most patients were not clinically depressed or anxious prior to surgery and the scores on the HADS are indicative of mild psychological distress. Surgery resulted in a general reduction in worry and anxiety, but also all four of the patients who were depressed prior to surgery, and two out of the six patients who were clinically anxious, improved to such a degree that they were no longer considered to be suffering from possible psychiatric disorder. These findings suggest that most of the psychological distress reported by women prior to surgery was a direct consequence of their dissatisfaction with their breasts. Body image is a subjective and abstract concept. It could be argued that neither of the questionnaires that were employed in this study to measure body image fully captured the complexity of this phenomenon. It is clear, however, that women reported a dramatic improvement in their satisfaction with their breasts following surgery and this change in attitude extended to the rest of the body, not just the breasts. There was no evidence of a shift in dissatisfaction to other parts of the body but, rather, the opposite occurred with women reporting greater satisfaction with the rest of their bodies. The SF36 has been used widely to measure health status and quality of life in a variety of different medical conditions.9–11 The patients in the present study showed mild to moderate impairment in their health status prior to surgery, whereas following surgery their scores were similar to those of the normal population, with the exception of one dimension: pain. The improvement in the SF36, in the present study, was comparable to improvements witnessed in other studies in this area.2,3 Breast reduction surgery appears to
451
have a positive effect on patients’ wellbeing across many aspects of their general health. It must be remembered that only patients with ‘enlarged breasts’ as assessed by plastic surgeons are considered for surgery on the NHS, and that all the women in this study had a breast cup size of at least ‘D’. Most of the women requested surgery on the grounds of discomfort, and improvement in appearance was a secondary consideration. The results of this study should not be generalised to the population of women with normal sized breasts who seek reduction. Two important methodological issues that need to be considered are sample size and response rate. The sample size in this study is small compared to similar studies but was large enough to demonstrate statistically significant change post-surgery. The response rate for patients willing to take part in the study was relatively low (63.5%), however, the follow-up rate for those undergoing surgery was high (95%); higher than all other previous studies. Provided patients agreed to meet the researcher preoperatively, they were happy to complete postoperative assessments, and every patient except one was reassessed. It is possible that some patients declined to participate in this study because they were reluctant to complete the psychological measures. We were unable to determine whether the patients who did not respond to the initial contact were psychologically different from the responders, although they were similar in all other respects. Three patients who were assessed and listed for breast reduction surgery changed their minds whilst on the waiting list. Although there is pressure to reduce waiting times for surgery, in some cases, having to wait a few months before operation may allow certain individuals time for further reflection upon their decision. The findings of this study confirm previous reports that physical status, health status and psychological symptoms improve with surgical intervention for enlarged breasts. The main reason for which patients seek surgery is discomfort rather than a cosmetic reason. There is no evidence that these patients are suffering from a body image disturbance, nor that they have high levels of psychiatric illness. Anxiety and depression are reported by a small number of patients and appear to be caused by the distress of having large breasts. The findings of this study support the argument for the inclusion of breast reduction surgery in NHS contracts. Acknowledgements We would wish to thank Mr Whitby and Mr Perkes for agreeing to their patients taking part in this study. We are also grateful to Mrs Tomenson, Medical Statistician, University of Manchester for statistical advice.
References 1. Hughes LA, Mahoney JL. Patient satisfaction with reduction mammaplasty: an early survey. Aesthetic Plast Surg 1993; 17: 345–9. 2. Klassen A, Fitzpatrick R, Jenkinson C, Goodacre T. Should breast reduction surgery be rationed? A comparison of the health status of patients before and after treatment: postal questionnaire survey. Br Med J 1996; 313: 454–7.
452 3. Shakespeare V, Cole RP. Measuring patient-based outcomes in a plastic surgery service: breast reduction surgical patients. Br J Plast Surg 1997; 50: 242–8. 4. Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand 1983; 67: 361–70. 5. Slade PD, Dewey ME, Newton T, Brodie D, Kiemle G. Development and preliminary validation of the body satisfaction scale (BSS). Psychology and Health 1990; 4: 213–20. 6. Hopwood P. Body Image Questionnaire. Department of Psychological Medicine, Christie Hospital, Manchester M20. Personal communication. 7. Ware JE Jr, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care 1992; 30: 473–83. 8. Wright L, Harwood D, Coulter A. Health and lifestyles in the Oxford Region. Oxford: Health Services Research Unit, 1992. 9. Mant JWF, Jenkinson C, Murphy MFG, Clipsham K, Marshall P, Vessey MP. Use of the short form-36 to detect the influence of upper gastrointestinal disease on self-reported health status. Qual Life Res 1998; 7: 221–6. 10. Ruta DA, Hurst NP, Kind P, Hunter M, Stubbings A. Measuring health status in British patients with rheumatoid arthritis: reliability, validity and responsiveness of the short form 36-item health survey (SF-36). Br J Rheumatol 1998; 37: 425–36. 11. Russo J, Trujillo CA, Wingerson D, et al. The MOS 36-item short form health survey: reliability, validity, and preliminary findings in schizophrenic outpatients. Med Care 1998; 36: 752–6.
British Journal of Plastic Surgery
The Authors Frederick Souza Faria MRCPsych, Consultant Psychiatrist Brookhaven, Princess of Wales Community Hospital, Stourbridge Road, Bromsgrove, Worcestershire B61 0DD, UK. Elspeth Guthrie MRCPsych, Senior Lecturer in Psychiatry University of Manchester, Rawnsley Building, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK. Eileen Bradbury PhD, Health Psychologist Department of Plastic Surgery, Withington Hospital, Manchester M20 8LR, UK. Anne Brain FRCS, Consultant in Plastic and Reconstructive Surgery Department of Plastic Surgery, Withington Hospital, Manchester M20 8LR, UK. Correspondence to Dr F. Souza Faria. The study was conducted by the first author during his Senior Registrar training in Psychiatry and no grants were obtained. Paper received 14 January 1998. Accepted 11 May 1999, after revision.
Psychosocial outcome and patient satisfaction following breast reduction surgery F. Souza Faria, E. Guthrie, E. Bradbury and A. N. Brain Department of Psychiatry, University of Manchester, Manchester Royal Infirmary, Manchester, UK SUMMARY. There is an increasing awareness that psychosocial outcome and health status are important outcomes following breast reduction surgery. In this study, patients awaiting breast reduction surgery completed detailed and comprehensive psychosocial assessments before and after surgery. Of 33 patients who completed the preoperative assessment, 20 patients were operated on and 19 were reassessed 4 months post-surgery. Patients expressed high levels of satisfaction with specific and overall results of surgery. Scores for anxiety, depression, body image and body satisfaction improved significantly using specific questionnaires. Patients also reported significant improvements on five out of eight subscales on the Short Form 36 health status questionnaire. This study provides further evidence for overall improvement in health status and psychological functioning in patients undergoing breast reduction surgery and supports the provision of this service by the NHS. Keywords: breast reduction, outcome, SF36, body image.
post-surgery assessment. In a similar study,3 patients were assessed on the day prior to surgery and at 3 and 6 months following surgery using the SF36 and Rosenberg’s self-esteem scales. The researchers initially assessed 110 patients and had a higher response rate of 82% at 3 months and 76% at 6 months, respectively. Significant improvements were reported in selfesteem and on six dimensions on the SF36 at 3 months, and on five dimensions at 6 months. Ninety six per cent of patients were satisfied with their surgery and there was a minor complication rate of 34%. However, neither of these studies included detailed psychological testing. Body image and body satisfaction are abstract but crucial issues in patients undergoing plastic surgery. The former refers to how an individual views his or her body in the mind’s eye and the latter alludes to subjective satisfaction with one’s body. The two are intimately related and to date have not been systematically investigated in patients undergoing breast reduction. The researchers decided to use two questionnaires; one designed to measure body satisfaction in patients suffering from eating disorders (Body Satisfaction Scale),5 and the other designed for use in patients undergoing reconstructive surgery for carcinoma of the breast (Body Image Scale).6 We wished to record patients’ perceptions of their breasts following surgery, and their perception of other parts of their body. It is possible that some patients requesting breast reduction surgery have a deep dissatisfaction with many parts of their body, not only their breasts. This negative body image may be related to low selfesteem and a general belief that they are overweight. In such patients, the focus of dissatisfaction with their bodies may shift following surgery to another part of their body (e.g. abdomen). Questionnaires which focus on the breast may miss this shift of focus and imply a good outcome, when in reality the patient has become
There has been considerable improvement in surgical techniques of breast reduction in the last three decades. However, research on psychosocial outcome, patient satisfaction and changes in quality of life have until recently been relatively neglected.1 There are at least two reasons why it is imperative that such research is carried out. The first is increasing public awareness of plastic surgery and the legitimate demand by patients for more information that is relevant to them. The second reason is the limitation of finances in a public health service and the need to make ‘evidence based’ decisions about the allocation of resources. Some health authorities have already put restrictions on breast reduction surgery and if the procedure is to remain available in the NHS there is a need to demonstrate not only a favourable physical outcome but also an overall improvement in quality of life and psychosocial functioning. In an early study1 an overall satisfaction rate of 80.6% was noted in 31 patients at 1 month postoperative follow-up. However, no standardised measures were used to measure health status and general wellbeing. Recently, two studies2,3 have recorded not only patient satisfaction but also changes in health status following surgery. Klassen et al2 in a large postal survey used three standardised measures to assess health status before surgery and 6 months after surgery. These were: the Short Form 36 health survey questionnaire which measures eight dimensions of health related quality of life, the General Health Questionnaire (measures psychological wellbeing) and Rosenberg’s self-esteem scale. Out of a total sample of 166, 128 (77%) were assessed preoperatively of whom 85 were operated during the study period and 58 (68%) reassessed after surgery. Significant improvements were reported on all three questionnaires including the eight subscales on the SF36. However, many were lost to follow-up with only 68% of patients completing the 448
Outcome of breast reduction
preoccupied with a different part of her body. It would be important to record whether similar changes were noted in the two relatively new scales. In addition, standardised measures of anxiety and depression (Hospital Anxiety and Depression Scale, HADS) and health status (SF36) were used to assess outcome following breast reduction surgery. Specifically, we wished to answer the following questions. Do patients who undergo breast reduction surgery show an improvement in psychological functioning and health status following surgery? Is there any evidence that patients’ previous dissatisfaction with their breasts is transferred on to a different part of their body after surgery? Patients and methods The study was conducted at the Department of Plastic Surgery, Withington Hospital between January 1995 and February 1996. All patients on the waiting list for three consultants who fulfilled the study criteria were approached. Patients below the age of 16 years or above 65 years were excluded. Patients living outside the Greater Manchester area were also excluded. Patients were initially sent a letter explaining the study, which was followed by a telephone call and were given the choice of taking part in the study by post or by person. All patients who took part in the study answered a semi-structured questionnaire which included the following: demographic details, bust size (e.g. 36DD), physical, psychological and social problems due to large breast size and changes hoped for following surgery. Patients were also asked to complete two well recognised psychological self-report questionnaires and two more specialised questionnaires. These were: 1. The Hospital Anxiety and Depression Scale (HADS) which is a widely used self-report scale of anxiety and depression, and was designed for use in patients with physical illness. Hence, items related to both physical and emotional disorder are excluded. It includes 14 items, 7 relating to anxiety and the remaining to depression resulting in one score for anxiety HAD(A) and another for depression HAD(D). A score of 8 or more on either the anxiety or the depression scale is the usual cut-off score for ‘caseness’.4 Patients scoring above the cut-off are deemed likely to have possible psychological disturbance of a clinically relevant nature. 2. The Body Satisfaction Scale (BSS) is a simple self-report questionnaire which was devised to record body image disturbances in subjects with eating disorders. The scale consists of a list of 16 parts; half involving the head (head, face, jaw, teeth, nose, mouth, eyes and ears) and the other half involving the body (shoulders, neck, breasts, abdomen, arms, hands, legs and feet). Subjects are asked to rate satisfaction/dissatisfaction with each of these body parts on a seven point scale.5 3. The Body Image Questionnaire (BIQ) is an eight item questionnaire devised to assess body image disturbance in patients undergoing mastectomy.
449
Patients are asked to rate their feelings regarding their appearance in the last week, and changes that may have occurred as a result of surgery, on a four point scale. Five items are related to general appearance and three specifically to the breast. These three items were modified for the purposes of this study and the word ‘scar’ was changed to ‘breast size’, i.e. ‘do you feel less eminine’/‘physically attractive’/‘sexually attractive due to your breast size’. The other five items relate to self-consciousness regarding appearance, dissatisfaction with one’s body, dissatisfaction when dressed, difficulty looking at self when naked and avoiding people because of the way one feels about one’s appearance.6 4. Short Form 36 (SF36) which is a well recognised measure of health status.7 It has eight subscales: physical function, role limitation (physical), role limitation (mental), social function, mental function, energy, pain and health perception. Scoring is out of 100 and a high score indicates good function.8 Approximately 4 months following surgery patients were contacted again and the above questionnaires were readministered by post. They were also asked to complete a postoperative satisfaction questionnaire including how pleased they were with shape, size and symmetry of their breast, nipple and scar as well as severity of postoperative pain (at 48 h and at followup; scale 0–10), any complications and overall satisfaction with surgery. All the assessments were conducted by FSF, a senior psychiatric trainee, who was independent of the plastic surgery department. The results were analysed using the Statistical Package for Social Sciences (SPSS). Continuous, normally distributed, data were compared using paired ttests (Hospital Anxiety and Depression Questionnaire and Body Image Questionnaire). Some of the data were not normally distributed, so the Wilcoxon Matched Pairs Signed-Rank Test was used for pre- and postoperative comparisons (SF36 and Body Satisfaction Questionnaire). Most of the results are presented in the form of means and standard errors of the mean (SEMs). Data which were not normally distributed are presented in the form of median and interquartile ranges (IQRs).
Observations and results Thirty-three out of 52 patients on the waiting list were assessed preoperatively. Of those remaining, 3 declined to take part in the study and 16 patients did not respond to a written invitation to attend an interview and were not contactable on the telephone. Ten patients were interviewed and the remaining completed the study by post. The non-attenders were similar in demographic characteristics to those who took part in the study but detailed psychological comparison between participants and non-participants could not be undertaken. Twenty out of 33 participants were operated upon during the duration of the study and
450
British Journal of Plastic Surgery
Table 1 Psychological symptoms Preoperative Variable HAD A HAD D Body Image
Postoperative
No. of pairs
Mean
SEM
Mean
SEM
P* (2 tail sig.)
19 19 19
7.6 5.6 17.2
0.9 0.8 1.3
4.3 1.0 3.7
0.7 0.2 0.9
0.009 <0.001 <0.001
*Paired t-test; SEM = standard error of the mean.
Table 2 Short Form 36 Preoperative Variable Physical fun Role limitation (physical) Role limitation (mental) Mental health Pain Health perception Social fun Energy and vitality
Postoperative
No. of pairs
Mean
SEM
Mean
SEM
P (2 tail sig.)
19 19 19 18 18 19 18 18
77.4 68.4 70.2 60.4 54.3 69.0 75.9 48.9
4.1 9.1 8.8 3.7 5.3 5.1 4.8 4.9
89.5 80.3 93.0 77.3 67.3 76.8 85.2 66.7
3.7 8.7 5.5 3.2 6.7 5.2 5.8 4.2
0.006 0.27 0.044 0.001 0.053 0.027 0.18 0.007
SEM = standard error of the mean.
100 90 80 70 60 50 40 30 20 10 0
Pre-operative Post-operative
vitality
Energy and
functioning
Social
perceptions
Health
Pain
health
Mental
mental
Role –
physical
Normative data
Role –
Mean and SEM
Patients scored significantly higher on five out of eight subscales of the SF36 Questionnaire following surgery indicating improvement (Table 2). These subscales were: physical function, role limitation (mental),
functioning
The mean score on the Body Image Questionnaire (BIQ) also improved significantly using paired t-tests (Table 1). Body satisfaction scores (Body Satisfaction Scale) were not normally distributed and hence
Health status SF36
Physical
Body image and satisfaction
analysed using Wilcoxon Matched Pairs Signed Rank Test and reported as median and interquartile range scores. Patients were significantly more satisfied with their bodies following surgery: preoperative median = 11, IQR (7–18); postoperative 6, (3–9); P = 0.005. The data were further analysed comparing remaining body parts excluding breasts. Patients’ scores for dissatisfaction were again significantly lower following surgery: preoperative 8, (4–15); postoperative 6, (3–9); P = 0.049.
SF-36 score
three patients aged 16, 21 and 22 years changed their mind about surgery. With the exception of one who moved away all the remaining 19 (95%) patients were assessed postoperatively. The mean duration of follow-up was 4 months (range 1–10). All 19 patients were satisfied with both their new breast shape and size and none felt their breasts were over or under reduced. Seventeen patients felt that their reduced breasts were symmetrical, although one patient was unsatisfied and another unsure. Eighteen patients were pleased with both the shape and size of their nipples although one was unsure. All 19 patients were satisfied with position of the scar, although 5 were unhappy with its healing. The mean score for pain was 5.6 out of 10 (SE = 0.6) at 48 h after surgery and 0.6 out of 10 (SE = 0.2) 4 months after surgery. Twelve out of 19 developed minor complications, mainly wound infection. Eight felt breast sensation was unaffected, six felt their breasts were less sensitive and five felt they were more sensitive. Sixteen were very satisfied with the outcome of surgery, three moderately satisfied and none were unsatisfied or unsure. Scores for anxiety and depression on the Hospital Anxiety and Depression Scale improved significantly following surgery (Table 1). The number of patients scoring above the cut-off point for caseness (i.e. possible psychiatric disorder) on the HADS for anxiety decreased from 6 to 4 following surgery and for depression from 4 to 0.
Figure 1—SF36 comparison of preoperative, postoperative and general female population from a large community sample in the Oxford Health Region.8
Outcome of breast reduction
mental health, health perception and energy and vitality. The improvement for pain was not quite significant (P = 0.053). The pre- and postoperative scores were further compared to normative data for the general female population (Fig. 1) which were obtained from a large community sample in the Oxford Health Region.8 The preoperative scores were significantly below the scores for the normal population on six out of eight subscales of the SF36, but following surgery the patients’ scores had improved to either normal or above normal scores, except for the pain subscale (Fig. 1). This could be explained by residual pain in some patients following recent surgery. Discussion This study confirms that high levels of patient satisfaction, decreased psychological symptomatology and improved health status follow breast reduction surgery. The high rates of satisfaction reported by the women post-surgery with the shape, size and symmetry of their breasts are similar to those reported in other studies of breast reduction surgery.1,3 Improvements in anxiety and depression scores on the HADS in the present study are comparable to the improvement in psychological wellbeing noted in a previous study, using the General Health Questionnaire.2 It is important to note that most patients were not clinically depressed or anxious prior to surgery and the scores on the HADS are indicative of mild psychological distress. Surgery resulted in a general reduction in worry and anxiety, but also all four of the patients who were depressed prior to surgery, and two out of the six patients who were clinically anxious, improved to such a degree that they were no longer considered to be suffering from possible psychiatric disorder. These findings suggest that most of the psychological distress reported by women prior to surgery was a direct consequence of their dissatisfaction with their breasts. Body image is a subjective and abstract concept. It could be argued that neither of the questionnaires that were employed in this study to measure body image fully captured the complexity of this phenomenon. It is clear, however, that women reported a dramatic improvement in their satisfaction with their breasts following surgery and this change in attitude extended to the rest of the body, not just the breasts. There was no evidence of a shift in dissatisfaction to other parts of the body but, rather, the opposite occurred with women reporting greater satisfaction with the rest of their bodies. The SF36 has been used widely to measure health status and quality of life in a variety of different medical conditions.9–11 The patients in the present study showed mild to moderate impairment in their health status prior to surgery, whereas following surgery their scores were similar to those of the normal population, with the exception of one dimension: pain. The improvement in the SF36, in the present study, was comparable to improvements witnessed in other studies in this area.2,3 Breast reduction surgery appears to
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have a positive effect on patients’ wellbeing across many aspects of their general health. It must be remembered that only patients with ‘enlarged breasts’ as assessed by plastic surgeons are considered for surgery on the NHS, and that all the women in this study had a breast cup size of at least ‘D’. Most of the women requested surgery on the grounds of discomfort, and improvement in appearance was a secondary consideration. The results of this study should not be generalised to the population of women with normal sized breasts who seek reduction. Two important methodological issues that need to be considered are sample size and response rate. The sample size in this study is small compared to similar studies but was large enough to demonstrate statistically significant change post-surgery. The response rate for patients willing to take part in the study was relatively low (63.5%), however, the follow-up rate for those undergoing surgery was high (95%); higher than all other previous studies. Provided patients agreed to meet the researcher preoperatively, they were happy to complete postoperative assessments, and every patient except one was reassessed. It is possible that some patients declined to participate in this study because they were reluctant to complete the psychological measures. We were unable to determine whether the patients who did not respond to the initial contact were psychologically different from the responders, although they were similar in all other respects. Three patients who were assessed and listed for breast reduction surgery changed their minds whilst on the waiting list. Although there is pressure to reduce waiting times for surgery, in some cases, having to wait a few months before operation may allow certain individuals time for further reflection upon their decision. The findings of this study confirm previous reports that physical status, health status and psychological symptoms improve with surgical intervention for enlarged breasts. The main reason for which patients seek surgery is discomfort rather than a cosmetic reason. There is no evidence that these patients are suffering from a body image disturbance, nor that they have high levels of psychiatric illness. Anxiety and depression are reported by a small number of patients and appear to be caused by the distress of having large breasts. The findings of this study support the argument for the inclusion of breast reduction surgery in NHS contracts. Acknowledgements We would wish to thank Mr Whitby and Mr Perkes for agreeing to their patients taking part in this study. We are also grateful to Mrs Tomenson, Medical Statistician, University of Manchester for statistical advice.
References 1. Hughes LA, Mahoney JL. Patient satisfaction with reduction mammaplasty: an early survey. Aesthetic Plast Surg 1993; 17: 345–9. 2. Klassen A, Fitzpatrick R, Jenkinson C, Goodacre T. Should breast reduction surgery be rationed? A comparison of the health status of patients before and after treatment: postal questionnaire survey. Br Med J 1996; 313: 454–7.
452 3. Shakespeare V, Cole RP. Measuring patient-based outcomes in a plastic surgery service: breast reduction surgical patients. Br J Plast Surg 1997; 50: 242–8. 4. Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand 1983; 67: 361–70. 5. Slade PD, Dewey ME, Newton T, Brodie D, Kiemle G. Development and preliminary validation of the body satisfaction scale (BSS). Psychology and Health 1990; 4: 213–20. 6. Hopwood P. Body Image Questionnaire. Department of Psychological Medicine, Christie Hospital, Manchester M20. Personal communication. 7. Ware JE Jr, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care 1992; 30: 473–83. 8. Wright L, Harwood D, Coulter A. Health and lifestyles in the Oxford Region. Oxford: Health Services Research Unit, 1992. 9. Mant JWF, Jenkinson C, Murphy MFG, Clipsham K, Marshall P, Vessey MP. Use of the short form-36 to detect the influence of upper gastrointestinal disease on self-reported health status. Qual Life Res 1998; 7: 221–6. 10. Ruta DA, Hurst NP, Kind P, Hunter M, Stubbings A. Measuring health status in British patients with rheumatoid arthritis: reliability, validity and responsiveness of the short form 36-item health survey (SF-36). Br J Rheumatol 1998; 37: 425–36. 11. Russo J, Trujillo CA, Wingerson D, et al. The MOS 36-item short form health survey: reliability, validity, and preliminary findings in schizophrenic outpatients. Med Care 1998; 36: 752–6.
British Journal of Plastic Surgery
The Authors Frederick Souza Faria MRCPsych, Consultant Psychiatrist Brookhaven, Princess of Wales Community Hospital, Stourbridge Road, Bromsgrove, Worcestershire B61 0DD, UK. Elspeth Guthrie MRCPsych, Senior Lecturer in Psychiatry University of Manchester, Rawnsley Building, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK. Eileen Bradbury PhD, Health Psychologist Department of Plastic Surgery, Withington Hospital, Manchester M20 8LR, UK. Anne Brain FRCS, Consultant in Plastic and Reconstructive Surgery Department of Plastic Surgery, Withington Hospital, Manchester M20 8LR, UK. Correspondence to Dr F. Souza Faria. The study was conducted by the first author during his Senior Registrar training in Psychiatry and no grants were obtained. Paper received 14 January 1998. Accepted 11 May 1999, after revision.