One goal of RM is to reduce breast volume and weight, which can cause upper/lower back pain, neck and shoulder pain, breast pain, headaches, and ulnar nerve paresthesia (7,9, 10, 11, 12, 13). Although these symptoms are often trivialized by those who do not have large breasts, preoperative RM patients score higher on standardized pain indexes as compared to persons suffering from arthritis and chronic low back pain (13).

Common physical findings that contribute to discomfort include shoulder grooving from bra straps that support the breast weight (7,9, 10,12, 13, 14, 15), stooped posture (9,14,16), intertrigo beneath the breasts caused by sweating and irritation within the inframammary crease (7, 8, 9, 10,12, 13, 14, 15, 16), and difficulty finding a comfortable sleeping position (8, 9,16). Decreased sensation in the skin, nipple, and/or areola also occurs with some frequency (17, 18, 19). Although not completely understood, two theories are most often postulated as causes of decreased sensation: (i) chronic traction injury to the sensory nerves resulting from the pull of gravity on a heavy breast, and (ii) decreased density of sensory nerve receptors in the expanded nipple-areolar complex (17). Measurable preoperative respiratory difficulties—and their significant improvement after surgery—also have been reported (20, 21).

For some women, the pain associated with breast hypertrophy may be severe enough to interfere with work. For example, 41% of reduction patients in one study had a working disability (on sick leave for some period of time) because of symptom severity (22). In addition, the pain and weight of very large breasts typically leads to reductions in exercise and engagement in everyday living activities, such as housework and playing with children. Studies have found that at least 83% of RM patients have difficulty taking part in physical activity most or all of the time prior to surgery (13,23).

The relationship between body mass and the physical symptoms associated with large breasts is equivocal. Several studies have suggested that the physical symptoms suffered by women who seek RM have been found to be independent of their body mass index (BMI) (9,24, 25). Other studies, however, have found an association between overall body mass and physical symptoms. For example, in comparing obese and non-obese RM patients, Glatt et al. found that obese women were significantly more likely to have neck pain, breast pain, and intertrigo than non-obese patients (14). Netscher et al. compared the physical and psychosocial symptoms of 31 women seeking breast reduction, 21 seeking breast augmentation, and 88 student volunteers who had never thought about breast surgery (26). Not surprisingly, the breast reduction group had a significantly higher mean weight, larger bra cup size, and larger bra circumference size. When all subjects were categorized according to small, medium, or large body mass, bra circumference size, and bra cup size, the large body mass index group was significantly more likely to report only three conditions: back/neck pain, shoulder pain, and rashes. When the women were categorized by
chest circumference, the large size group was significantly different on four conditions: back/neck pain, shoulder pain, rashes, and appearance concerns. When categorized according to bra cup, the large size group was significantly more likely to report back/neck pain, shoulder pain, rashes, breathing problems, tingling/numbness in upper extremities, activity limitations, and reduced exercise participation. Thus, a large bra cup size was associated with more of the physical symptoms of breast hypertrophy than either body mass or bra circumference.

The physical symptoms of macromastia appear to vary by age. Almost half (48%) of breast reduction patients are between the ages of 19 and 34 (1). Thirty-six percent are between 35 and 50 years old, 14% are 18 or younger, and 2% are 51 years old and older. Complaints about physical symptoms are more often voiced by women in their 30s and older, perhaps because of the accumulated years of carrying heavy and disproportionate weight on the chest, which can place unnatural loading on the upper body skeleton and musculature (27). However, studies that looked specifically at teenagers with breast hypertrophy found that large majorities of them—up to 100% in some studies—also reported back, neck, or shoulder pain (28, 29).

Breast hypertrophy may have a profound effect on women’s lives by contributing to heightened self-consciousness, poor self-esteem, decreased confidence, and a negative body image (6,10,16,30, 31, 32). Large breasts can interfere with a woman’s ability to have an active lifestyle and make it difficult to find clothing, swimsuits, or underwear that fit (6,10,16,30, 31, 32). Almost two-thirds of RM patients questioned before surgery “almost always” or “often” felt unattractive, and 40% felt their breast size adversely affected their sex lives (31).

Although younger patients suffer from physical problems, they may be more strongly motivated to have surgery because of psychosocial concerns (29,33). In addition to being the brunt of jokes and teasing comments related to their breast size during their formative years, teenagers may experience a great deal of unwanted attention from their male peers, who tend to pay more attention to their large breasts than see the person behind them (29). Adolescent girls with breast hypertrophy are often unable or embarrassed to wear bathing suits and fashionable clothing commonly worn by their peers (29). As a result, they may adopt strategies to camouflage their breasts, such as wearing baggy clothing, adopting a stooped posture, or intentionally gaining weight. If untreated, the emotional and social repercussions of abnormally large breasts in adolescence may resonate throughout adulthood.

Deliberate weight gain to hide macromastia is not uncommon among young women. Increased breast size also may inhibit a young woman’s ability to engage in regular exercise or organized sports as a way to maintain a healthy lifestyle and normal body weight. While some teenagers choose to gain weight, others may develop eating disorders (34, 35). One study reported on nine young women with bulimia nervosa who wore DD or DDD bra cup sizes by their mid-teens and began binge eating and purging as an inappropriate weight control strategy (35). After RM, eight of the nine had recovered from bulimia, and the one still recovering had reduced her binging and purging episodes by 80% (35).

Several studies have investigated the psychological motivations of RM using a variety of psychometric measures. In particular, quality of life, body image, depressive, and anxiety-related symptoms have received the greatest empirical attention.

Quality of life is a significant concern of women who seek breast reduction. The well-validated and standardized Medical Outcomes Survey Short Form-36 (SF-36) has been used most often to assess the health-related quality of life of breast reduction patients. The SF-36 has eight subscales: physical function, role limitation (physical), role limitation (mental), social function, mental function, vitality and energy, pain, and health perception. Several investigators have compared the
preoperative scores of RM patients with normal controls from the general population and found that patients scored significantly lower than population controls on six (16,30) to all eight quality of life dimensions (11,13,31,36).

Other studies have examined additional psychological symptoms potentially related to breast hypertrophy. Using the Brief Symptom Inventory (BSI), Behmand et al. found that RM candidates had significantly higher ratings for depression, anxiety, interpersonal sensitivity, and hostility when compared to normal controls (36). Scores from preoperative RM patients on the Hospital Anxiety and Depression Scale (HADS) revealed significantly more symptoms of depression and anxiety when compared with an age-matched control group of large-breasted women who did not want surgery (30). The women who wanted surgery also had lower self-esteem and greater interpersonal difficulties than the large-breasted controls (30). Additionally, the surgical patients reported significantly more physical symptoms and limitations than the controls, which may have contributed to the pursuit of surgery.

Sarwer et al. compared the body image concerns of 30 breast reduction patients to 30 women who sought breast augmentation and found greater body image dissatisfaction among RM patients (32). The two groups of patients differed on seven of the ten subscales of the Multidimensional Body-Self Relations Questionnaire (MBSRQ), with preoperative breast reduction patients scoring significantly lower than preoperative augmentation patients on Appearance Evaluation, Body-Areas Satisfaction, Fitness Evaluation, Fitness Orientation, Health Evaluation, Health Orientation and Self-Classified Weight subscales. Using the Body Dysmorphic Disorder Examination-Self-Report (BDDE-SR) (adapted in this study for use as a measure of breast dissatisfaction), they also found that women who sought RM were significantly more dissatisfied with their breasts than women who sought augmentation (32). In addition, reduction patients were significantly more embarrassed about their breasts in public areas and in social settings and more likely to avoid physical activity because of self-consciousness about breast size. Furthermore, a significantly greater number of reduction patients believed their breast appearance was abnormal.

All plastic surgeons must be watchful for patients who may be suffering from psychological disturbances, especially body dysmorphic disorder (BDD) (see Chapters 14 and 16). However, clinical experience suggests that BDD is rarely encountered in women who seek breast reduction. Patients seeking RM have a real physical problem that is readily apparent, and they rarely, if ever, exaggerate its seriousness or its impact on their lives. When the obvious deformity is treated surgically, RM patients are unlikely to become fixated on another body area that they feel needs surgical correction.

The emotional pain and reduced quality of life suffered by women seeking breast reduction can be assessed with a variety of psychometric instruments. These measures can provide both patients and surgeons with a wealth of information about the specific psychosocial concerns experienced by patients prior to surgery. Specific questions in the initial consultation, as shown in Questionnaire 12-1 at the end of this chapter, can provide additional information on the extent of psychological distress resulting from breast hypertrophy. These questions easily can be worked into the surgeon’s typical patient evaluation strategy to ascertain which specific concerns seem to have the greatest impact on prospective patients. They should also help surgeons determine whether a psychiatric consultation might be warranted, especially if a patient’s psychological distress is excessive and inconsistent with the degree of breast hypertrophy observed.