Abstract
Background
Few studies have examined persistent pain after reduction mammaplasty, and sensory changes remain a controversial subject with studies reporting both reduced, improved, and unchanged skin sensitivity following surgery. The aim of the present study was to describe the prevalence, character, and impact of sensory changes and persistent pain following breast reduction surgery and to assess possible causes and predictors of persistent sensory changes and chronic pain.
Methods
In May 2010, a detailed questionnaire was mailed to all 109 patients who underwent reduction mammaplasty at the Department of Plastic Surgery, Aalborg Hospital from September 2004 to February 2010. Ninety patients (83%) returned the questionnaire; mean age was 48.7 years (SD 14.7); and mean time since surgery was 27.7 months.
Results
Eight patients reported that they had sensory abnormalities in the breasts before surgery, which normalized or improved in four, remained unchanged in one, and worsened in three patients following surgery. Forty-nine patients (54%) reported sensory changes in the nipple–areola complex or skin as a consequence of surgery. Sixty-nine patients reported having pain before surgery (most often in the neck/back), which was completely relieved in 42% and partially in 43%. Twenty-five patients (28%) reported having pain in the breasts as a consequence of the operation: 20% had chronic pain (defined as constant pain or pain at least once weekly for at least 3 months) and 7% had moderate to severe pain. In more than half of the patients, the pain was compatible with neuropathic pain. Patients with pain tended to be less satisfied with the surgery than those without pain (p = 0.07, Mann–Whitney U test). Young age, time since surgery, complications to surgery and sensory abnormalities before surgery were significantly related to pain.
Conclusion
Reduction mammaplasty relieved neck and back pain in most patients, but the surgery is associated with a risk of developing new sensory abnormalities and persistent neuropatic pain.
Implications
The clinical implication of this study is that reduction mammaplasty may sooth preexisting neck- and back pain, but may lead to a new condition in the patient with chronic sensory changes and pain in the breasts.
1 Introduction
Chronic postoperative pain develops in a substantial proportion of patients but is a relatively neglected problem, and the underlying mechanisms are not fully understood. Chronic pain has been reported after both minor and major surgery like hernia repair, cesarean section, mastectomy, and thoracotomy [1,2,3].
Only a few studies have examined chronic pain after breast reduction, and the risk of developing chronic pain after reduction surgery thus remains unclear. Wallace et al. [4] investigated pain after breast surgery in 282 women undergoing either mastectomy with and without reconstruction, breast augmentation, or breast reduction. The incidence of pain was highest in the group of women who underwent mastectomy with reconstruction (49%), in women who underwent mastectomy it was 31%, and in women who underwent breast augmentation it was 38%. The lowest incidence of pain was found in the group of women who underwent breast reduction (22%). Blomqvist et al. [5] in a prospective questionnaire study of 49 women showed that reduction mammaplasty provided significant reduction of regional pain. Spector et al. [6] also found significant pain reduction 3 and 6 months after breast reduction.
Different predictive factors for chronic postoperative pain in general have been identified, related to both patient characteristics and surgical factors, including female gender, young age, obesity, preoperative anxiety and/or catastrophizing, pre-existing pain, genetic factors, and nerve injury during surgery [7].
Changes in breast sensibility after breast reduction have been reported earlier, but the findings are controversial. The nipple–areola complex and the skin are innervated by the anterior and lateral cutaneous branches of the third, fourth, or fifth intercostal nerves, with frequent variations, including innervation from the second and sixth intercostal nerves [8]. The lateral cutaneous branch often takes a subglandular course within the pectoral fascia innervating the nipple from its posterior surface. The anterior branches run in a parasternal line towards the nipple–areola complex innervating it from the medial surface [9].
Some studies have reported decreased nipple–areola sensibility following breast reduction [10,11], while others have failed to demonstrate such changes in sensibility [12,13] or even improvement of the breast sensibility and localized pain [14]. Slezak and Dellon [15], suggested that a chronic traction injury to the intercostal nerves in patients with mamma hypertrophy may cause sensory abnormalities which are improved after surgery due to reinnervation from intercostal and supraclavicular nerves.
According to the Danish Registry for Plastic Surgery of the Breast [16] 2547 women (4927 breasts) had breast reduction surgery from June 1999 to December 2006. Reduction surgeries were performed either on a cosmetic or medical indication. Indications for having breast reduction surgery in a public hospital in Denmark requires the removal of a minimum of 500 g of tissue per breast, a BMI below 25, symptoms of mammary hypertrophy, which may include upper back, neck, and shoulder pain, and skin problems in the inframammary folds. Indications also include cosmetic or medical issues as part of the recovery after mammary cancer.
Based on a questionnaire, the present study examined the prevalence of persistent sensory changes and pain after breast reduction surgery, the relationship between postoperative sensory abnormalities and pain, and the impact of sensory changes and pain on daily activities. We hypothesized that nerve injury with the resultant sensory changes is a major underlying cause of persistent pain after breast reduction surgery.
2 Methods
2.1 Design and study population
This study was a cross-sectional postal survey, which included a self-administrated questionnaire as well as information from medical records. In May 2010, a detailed questionnaire was mailed to all 114 patients who had undergone breast reduction surgery at the Department of Plastic Surgery at Aalborg Hospital from September 2004 to February 2010; 109 patients were included. Five patients were excluded from the study: one patient was retarded and four patients had no official postal address.
A second mailing was done in July 2010 to non-responders. A telephone call or e-mail was made if needed and permission given for clarifying missing or unclear questions. The study was approved by the Danish Data Protection Agency (no. 2010-41-4869).
The surgical Orlando technique, i.e. using a superomedial pedicle for nipple transposition [17] was performed in all cases. Patients were operated in general anesthesia supplemented by preoperative infiltration inferior to the nipple–areola complex with a 40ml solution of 40 ml lidocaine, 10 mg/ml + adrenaline 5μg/ml and with 40 ml saline.
Surgeons used drains when needed. The standard anesthetical regime was given preoperatively using remifentanil, propofol, morphine, and sometimes fentanyl. Postoperatively the regime was supplied with paracetamol 1mg four times daily and ibuprophen 400mg three times daily if needed.
2.2 Measures
The self-administered questionnaire included questions on demographic and lifestyle factors, previous surgery, and indication for surgery. Information about postoperative infection and complications, as well as satisfaction with the operation measured on a numeric rating scale (NRS, 0 = not satisfied, 10 = very satisfied) was obtained together with information on sensory abnormalities (hypo- or hypersensitivity) before and after surgery, their location, and how much they bothered the patients (NRS, 0–10), pain unrelated to breast surgery, and pain as a consequence of the breast surgery. Those who reported pain as a consequence of the breast surgery the preceding month were also asked about the impact of the pain on daily activities measured on an NRS (0 = no impact, 10 =worst impact imaginable), pain location (by mapping the areas on a body chart of the chest and arms), pain onset, pain at rest and on movement, touch-evoked pain, pain intensity (NRS, 0 = no pain, 10 = worst pain imaginable), pain treatment, and if the patient had regretted the surgery due to pain. Pain descriptors were assessed using the neuropathic pain diagnostic questionnaire (DN4; [18]) translated into Danish. The self-administered 7-item (burning, painful cold, electric shocks, tingling, pins and needles, numbness, and itching) DN4 questionnaire has been shown to have a sensitivity of 81.6% and a specificity of 85.7% in diagnosing neuropathic pain for a cut-off score of 3 of 7 scores [18].
Medical record data from the preoperative consultation, surgery (technique, date, amount of tissue reduced), and postoperative clinical follow-up were extracted from hospital records.
2.3 Statistical analysis
Data are presented as mean and standard deviation (SD) or as median (range). We used the t-test and the Mann–Whitney U test where appropriate and the χ2 and Fisher’s exact test for dichotomous data. Odds ratios (OR) with 95% confidence intervals were calculated using standard 2×2 tables. p < 0.05 was considered statistically significant. There were not enough cases for multiple logistic regression analysis.
3 Results
3.1 Patients
Ninety patients (83%) answered the questionnaire. Eighty-four patients answered the first questionnaire and six responded to the reminder. There was no significant difference in age between those who responded to the questionnaire and those who did not (48.7 years (SD 14.7) and 42.6 years (SD 12.4), p = 0.07, t-test). Mean age was 48.7 years (SD 14.7) and mean BMI 26.3 (SD 5.8). Mean time since operation was 27.7 months (SD 16.9, range 3–55 months) (Table 1). Sixty-nine patients reported that the indication for surgery was medical (mainly pain in the neck and shoulders), 11 reported cosmetic improvement of symmetry after treatment for breast cancer, and 10 reported cosmetic indication only.
Clinical characteristics of 90 patients having breast reduction surgery and comparison between patients with and without persistent postoperative pain.
| Patient characteristics | Total population | Patients with pain | Patients without pain | p-Value or OR (95% CI) |
|---|---|---|---|---|
| Number of patients (response rate) | 90 (83%) | 25 | 65 | |
| Age, years, mean (SD) | 49(15) | 43(16) | 51 (14) | 0.03 |
| Age <50 years | 42 (47) | 17(68) | 25 (39) | 3.4 (1.3–9.0) |
| Time since surgery, months, mean (SD) | 28 (17) | 21 (17) | 30(16) | 0.02 |
| Time since surgery <2 years | 40 (44) | 16(64) | 24 (38) | 3.1 (1.2–7.9) |
| Smoking | 10(11) | 3(12) | 7(11) | 1.1 (0.3–4.8) |
| Reduced weight per breast, g, median (range) (16 unilateral), n = 63 Complications | 657(70–3975) | 663 (280–3974) | 650(70–1782) | 0.6 |
| Self-reported | 38 (42) | 15 (60) | 23 (35) | 2.7 (1.1–7.1) |
| Evaluated by surgeon at control visit (infection = 23, hematoma = 7) | 32 (36) | 14(56) | 18(28) | 3.3(1.3–8.7) |
| Pain before surgery | 69 (77) | 20 (80) | 49 (75) | 1.3 (0.4–4.0) |
| Persistent pain (mainly neck/back) | 40 (44) | 15 (60) | 25 (39) | 2.4 (0.9–6.2) |
| Frequency of pain elsewhere | 26 (29) | 7(28) | 19(29) | 0.9 (0.3–2.6) |
| Sensory abnormalities | 49 (54) | 19(76) | 30 (46) | 3.7(1.3–10.4) |
| Hypoesthesia | 40 (44) | 15 (60) | 25 (39) | 2.4 (0.9–6.2) |
| Hyperesthesia | 18(20) | 10(40) | 8(12) | 4.8(1.6–14.1) |
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Odds-ratio (OR) (chi-square) with 95% confidence interval (CI)
3.2 Sensory changes and pain before operation
Sixty-nine patients reported having pain before surgery, which was completely relieved in 42% and partially in 43%. Sixty-seven patients reported they had pain in the neck/back before surgery, 33 reported complete relief of pain following surgery, 24 partial relief, and 10 no relief. In patients with no or partial pain relief (n = 34), the current median pain intensity was 5.0 (range 0–10). Eleven patients reported having pain in the breasts before surgery, which was relieved by surgery in seven and partially relieved in four (pain intensity in the past week was 2 in three patients and 0 in one patient). Eight patients reported that they had sensory abnormalities in the breasts before surgery, which normalized or improved in four, unchanged in one, and worsened in three patients following surgery.
3.3 Sensory changes and pain following surgery
Forty-nine patients (54%) reported sensory changes as a consequence of the operation; 40 patients (44%) reported decreased sensation and 25 (28%) increased sensation over the breast (Fig. 1). The areas of sensory changes were mostly located to the nipple–areola complex and to a lesser degree around the vertical or inframammary scars (Fig. 2). Sixty-five percent of patients with decreased sensation reported that they were bothered by this, median NRS score 3 (range 1–9), and 78% of those with increased sensation reported that they were bothered by this, median NRS score 4 (range 1–10).
Areas of sensory changes and pain following breast reduction surgery. Typical examples of patient drawings of areas of sensory loss (upper panel), increased sensation (middle panel), and pain in periareolar, vertical, and inframammary scars (lower panel).
Twenty-five patients (28%) reported having pain within the last month as a consequence of the operation. Eighteen patients (20%) had chronic pain (defined as constant pain or pain at least once weekly for at least 3 months). Median pain intensity on the NRS was 2 (range 0–10). The pain was moderate to severe (defined as 4 or above on the NRS 0-10) in six patients (7% of the total population), and in six patients (7%) the pain affected daily activities (median 3, range 1–5) (Fig. 1). Two patients took over-the-counter pain medication (paracetamol, ibuprophen) less than twice weekly. Of the total population, four patients with pain, and five patients without pain regretted the surgery (p = 0.44, Fisher’s exact test). Patients with pain tended to be less satisfied (median 8, range 1–10) than those without pain (median 9, range 0–10) (p = 0.07, Mann–Whitney U-test).
3.3.1 Pain characteristics
Onset was reported to be immediately after the operation in 10 patients, within 3 months of surgery in six, after 3 months in four, while five patients did not recall onset. The pain was located to the inframammary fold in 14 patients, the nipple–areola complex in 12 patients, and covered a larger area of the breast in six patients (Fig. 2). Thirteen patients (52%) had rest pain, and eight patients (32%) had worsening of the pain by physical movement (running, stretching arms, switching sides when lying down/sleeping). The pain was most often intermittent, lasting for days in two, hours in three, minutes in six, and seconds in 14 patients. Upon self-examination (stroking the breast lightly with the fingertips), 13 patients (52%) reported touch-evoked pain (allodynia) (median intensity NRS 3, range 1–10).
Sensory changes and pain following breast reduction surgery. Percentage of 90 patients who reported sensory changes, pain, and pain with impact on daily life following breast reduction surgery.
3.3.2 Possible neuropathic pain
Thirteen patients (52%) met the DN4 cut-off criteria for neuropathic pain (3/7), while 33 patients had 2 or more descriptors. Pins and needles were reported by 18 patients, itching by 18, numbness by 10, tingling by nine, burning by eight, electric shocks by eight, and painful cold by one. Of the total population, 16 had pain in an area of abnormal sensation, and 14 (56%) had pain in an area of abnormal sensation, and in addition allodynia and/or a DN4 score >3.
3.3.3 Factors associated with chronic postoperative pain
Young age, short time since surgery, complications to surgery, sensory abnormality, and sensory hypersensitivity were associated with a higher risk of reporting pain (Table 1). The suggested association between sensory changes and persistent pain was unaltered by analyzing separately patients above or below 50 years, time since surgery above or below 2 years, and patients with or without complications.
4 Discussion
The study confirms previous findings [4,10,11,14,15] that sensory changes occur in a large proportion of women who undergo breast reduction surgery. Fifty-four percent reported having sensory changes after surgery, of these 44% had decreased sensation and 28% had increased sensation on the skin or nipple–areola complex. The study also confirmed previous findings that persistent postoperative pain develops in a significant proportion of patients, but in less than following other breast surgeries [4]. Eighteen patients (20%) had chronic pain, which was moderate to severe in six patients (7% of the total population), consistent with a previous study reporting pain in 22% [4]. Young age and shorter time since surgery were related to the presence of pain. Sixty-seven patients (73%) reported having neck/back pain before the operation, and of these 33 (49%) had total relief of their pain following surgery. It is relevant to consider, that expectations to surgery postoperatively may have a placebo effect on neck/back pain in some patients. Thirty-four patients had no or partial relief of neck/back pain.
The response rate was 83%, which we believe is a representative sample of patients of the whole population in the current pain clinic.
Of the total population, 16 had pain in an area of abnormal sensation, and 14 (56%) had pain in an area of abnormal sensation, and in addition allodynia and/or a DN4 score >3. Thus, neuropathic pain may be present in about half of the patients reporting pain. By using the Orlando technique for breast reduction surgery, a relatively large proportion of the skin is reduced together with the mammary/glandular tissue. This may lead to cutting off nerve supply from the lower part of the intercostal nerves that innervate the nipple–areola complex and the skin. Postoperative complications (hematoma, infection) are other known predictors for developing chronic postoperative pain [19,20] which was also found in this study showing that patients who had postoperative complications treated in the ward had a significantly higher risk of developing pain (OR 3.3 (1.3–8.7)). The association between the presence of pain and time since surgery suggests that pain persisting beyond 3 months May still resolve, consistent with previous findings following breast augmentation [21,22].
Different types of breast surgery procedures lead to different sensory and pain outcomes. Mastectomy and breast augmentation are both procedures with a high frequency of persistent pain [4,23]. Using the same questions, we found that breast reduction surgery produces larger scars compared with breast augmentation, but fewer sensory changes and less chronic pain [24]. It is possible that breast augmentation, due to the forming of a subglandular/submuscular pocket and the chronic stretching of nerve endings caused by the implants, causes more nerve damage than the surgery for mamma hypertrophy despite the smaller skin incisions.
In conclusion reduction mammaplasty relieved neck and back pain in most patients, but the surgery is associated with a risk of developing new sensory abnormalities and persistent neuropathic pain.
DOI of refers to article: 10.1016/j.sjpain.2011.02.002.
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Conflict of interest: None declared.
Acknowledgements
The study was supported by the Velux Foundation. The authors would like to thank research secretary Helle Obenhausen Andersen for language revision.
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