Risk Factors for Complications after Reduction Mammoplasty: A Meta-Analysis
et al. (2016) Risk Factors for
Complications after Reduction Mammoplasty: A
Meta-Analysis. PLoS ONE 11(12): e0167746.
Risk Factors for Complications after Reduction Mammoplasty: A Meta-Analysis
Min-Xia Zhang 0 1
Chun-Ye Chen 0 1
Qing-Qing Fang 0 1
Ji-Hua Xu 0 1
Xiao-Feng Wang 0 1
Bang-Hui Shi 0 1
Li-Hong Wu 1
Wei-Qiang Tan 0 1
0 Department of Plastic Surgery, The First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou, Zhejiang Province, P.R China , 2 Department of Plastic Surgery, The Fourth Affiliated Hospital, College of Medicine, Zhejiang University , Yiwu, Zhejiang Province, P.R China
1 Editor: Leila Harhaus, BG Trauma Center Ludwigshafen , GERMANY
Reduction mammoplasty (RM) is a proven method of treating macromastia, but the risk factors for postoperative complications have not been clearly identified. Through this metaanalysis, the authors aimed to identify the risk factors of RM complications. An extensive search of the literature describing complications after RM was performed using the PubMed Central, Embase, and Cochrane databases. The following risk factors were extracted: age, body mass index (BMI), tissue resection weight per breast (TRW), smoking and radiation therapy. Odds ratios (OR) were pooled with 95% confidence intervals (CI) to evaluate the relationship between these risk factors and complications after RM.
Data Availability Statement: All relevant data are
within the paper and its Supporting Information
Competing Interests: The authors have declared
that no competing interests exist.
A total of 16 unique studies including 10 593 patients were included in the final analysis. It
showed that there was a significant difference in complications in BMI 30 kg/m2 (OR 0.73;
95% CI: 0.61±0.89, p = 0.001) and smoking (OR 1.56; 95% CI: 0.98±2.49, p = 0.06).
Infection in those with BMI 30 kg/m2 showed a significant difference (OR 0.68; 95% CI: 0.52±
0.89, p = 0.004), as well as wound dehiscence in smokers (OR 2.73; 95% CI: 1.60±4.67, p =
0.0002) and infection in irradiated breasts (OR 20.38; 95% CI: 3.42±121.35, p = 0.0009).
However, there was no significant difference in age 50 years (OR 0.96; 95% CI: 0.71± 1.29, p = 0.78), combined TRW 1000 g (OR 1.04; 95% CI: 0.43±2.50, p = 0.93).
BMI 30 kg/m2 and smoking increase the risk of complications. Persons who are obese or
irradiated are more likely to develop infections, and smokers experienced a higher incidence
of wound dehiscence than did nonsmokers. However, patients aged 50 years and TRW
1000 g are not associated with complications from RM.
Macromastia is a common problem among women, leading to disabling symptoms such as
neck, back, and shoulder pain; inframammary maceration; heavy breathing during exercise;
and great psychological burdens because of unaesthetic appearance. Reduction mammoplasty
(RM) is an approved procedure for women with macromastia, which has effectively relieved
existing symptoms with high satisfaction, even though complications have often occurred [1±
4]. Risk factors for complications are major determinants in surgical planning. Effectively
predicting and preventing complications in RM has become an important research field.
However, no predictors have been clearly recognized.
Postoperative complications after breast reduction include infection, wound healing
problems, scars, fat necrosis, seroma, lost nipples and reoperations. The complications occurred
after breast reduction would be as high as 40 or 50% in reported studies [
3, 5, 6
]. Many studies
have reported preoperative factors that impacts complication rates [
]. Increased body mass
index (BMI) is often deemed a critical risk factor for postoperative complications [
5, 9, 10
Some analyses provide contradictory suggestions [11±13], which may be due to small sample
size. Other reported risk factors are age, smoking, tissue resection weight per breast (TRW),
radiation therapy and so on [
6, 14, 15
Almost all the risk factors associated with complications were controversial and no
published meta-analysis had investigated it. We therefore performed a meta-analysis of all
published prospective and retrospective studies to evaluate the important risk factors in women
with macromastia and gigantomastia and provide preliminary guidance for clinical treatment
Materials and Methods
We prospectively defined the study objectives, search paramters, eligibility criteria, and
The following electronic databases were searched: The PubMed Central, Embase, and
Cochrane Library. They were searched for English language studies using the following
headings and keywords: macromastia or gigantomastia. Also used were breast reduction, reduction
mammaplasty or reduction mammoplasty. No limitation was put on the date of publication,
which covered all previously published studies up to December 2015. In addition, selected
study references and review articles were examined for further article sources.
The initial selection of studies was performed on the basis of titles and abstracts. Next, two
investigators (Min-Xia Zhang and Chun-Ye Chen) independently screened the full text of
each selected study using the following inclusion criteria: (1) the study must meet the
definition of macromastia or gigantomastia; (2) RM as the only surgical procedure of interest; (3)
measured complications of the incidence and risk factors of RM; (4) risk factors were BMI,
age, TRW, smoking or radiation therapy, any one of which should be researched in the study;
(5) Sufficient data on contrasting groups. Studies were excluded if they contained any one of
the following exclusion criteria: (1) case reports, abstracts only, letters, comments or reviews;
(2) studies with mixed gender or surgical procedures; (3) virginal, adolescent or pregnant
macromastia. To avoid double publication, only the most informative or lastest study was
2 / 13
included. This meta-analysis was performed in accordance with the Preferred Reporting Items
for Systematic Reviews and Meta-Analyses (PRISMA) statement checklist.
Data extraction was performed independently by two reviewers (Min-Xia Zhang and Chun-Ye
Chen), and any disagreement concerning paper eligibility was resolved by discussion and
consensus. The data covered the general characteristics of each study and the outcomes measured.
In addition, studies were assigned a level of evidence score.
Based on the amount of data available and on clinical relevance, five factors were analyzed
including BMI, age, TRW, smoking and radiation therapy.
For each risk factor in our study, odds ratios (OR) and 95% confidence intervals (CI) were
calculated for outcomes. A p value <0.05 was judged as statistically significant. Random-effects
models were used depended on the heterogeneity of the studies included. Heterogeneity was
analyzed with both the Chi squared test I square test, where p value <0.10 for the Chi squared
and I2 50% implied heterogeneity [
]. The forest plot was a graphic presentation of the
Data was processed in Review Manager version 5.3 from the Cochrane Collaboration.
Study identification and selection
A total of 2532 records were identified by the initial database search, from which 63 full-text
articles were retrieved for final review after screening titles and abstracts. Of these, 16 studies
that met all predefined inclusion criteria were finally included in our meta-analysis [5, 6, 11,
14, 15, 17±27]. Fig 1 shows study selection through the processes of identification, screening,
and eligibility (Fig 1). Evidence for and against each risk factor is stratified in Table 1.
Study characteristics for the 16 included studies are summarized in Table 2. These studies
were published before December 2015. There were three prospective studies while the others
were retrospective ones. Mean postoperative follow-up time was noted in nine studies [6, 11,
15, 21±26] and occurred from 1 to 32.9 months after surgery. Five studies [5, 17±19, 27] did
not report follow-up time, and the last two studies [
] only reported a range.
Patient and treatment characteristics
The study set included altogether 10 593 patients whose demographic features (age, BMI,
smokers, TRW, operating time and techniques) are displayed in Table 3, with some studies
providing detailed information and others not. The overall incidence of complications of 11
studies [6, 11, 14, 15, 17, 18, 20±24] was 11.0% (ranged 5% to 56%), while the rest [5, 19, 25±
27] reported only some specific complications, lacking the total quantities. Various operative
techniques were used, in which the most frequent technique was the inferior pedicle with an
average percentage of 46.0%. The medial pedicle and central mound technique were
exclusively used in 2 studies, respectively. The vertical scar pattern was also used frequently, as well
as the superomedial pedicle and free nipple graft.
3 / 13
Fig 1. Preferred Reporting Items for Systematic Reviews and Meta-Analysis flow diagram, literature
search, and selection process.
TRW 1000 g
Cunningham BL et al. 2005; Shah R et al. 2011
Cunningham BL et al. 2005; Schumacher HH
et al. 2005; Kendall R et al. 2008; Roje Z et al.
2012; Nelson JA et al. 2014 (age); Guemes A
et al. 2015; Setala L et al. 2009
Schumacher HH et al. 2005; Kendall R et al. 2008; 1.04 (0.43±2.50)
Roje Z et al. 2012; Guemes A et al. 2015
Cunningham BL et al. 2005; Kendall R et al. 2008; 1.56 (0.98±2.49)
Guemes A et al. 2015
BMI 30 kg/m2
Age 50 yrs
4 / 13
R-COH: retrospective cohort; P-COH: prospective cohort; LOE: level of evidence; NR: not reported
NO. Of patients (breasts)
Assessment of risk factors of complications
The risk factors with sufficient data of complications available for meta-analysis were BMI,
age, TRW, smoking and radiation therapy. The results were expressed as ORs, 95% CIs and
BMI 30 kg/m2. We first divided the patients into two groups: non-obese (BMI <30 kg/
m2) and obese (BMI 30 kg/m2). BMI 30 kg/m2 was the strongest risk factor for overall
complications in our meta-analysis based on 6 related studies [11, 14, 17, 21±23]. The test for
heterogeneity was not significant (p for heterogeneity = 0.88; I2 = 0%). The aggregated results
suggest that BMI 30 kg/m2 was highly associated with a significant increase in the overall
incidence of complications after RM (OR 0.73; 95% CI: 0.61±0.89, p = 0.001) (Fig 2).
Moreover, the aggregated results of the 4 studies [
11, 17, 21, 23
] suggest that BMI 30 kg/m2 was
highly associated with a significant increase in the incidence of infection (OR 0.68; 95% CI:
0.52±0.89, p = 0.004) (Fig 3). The test for heterogeneity was not significant (p for
heterogeneity = 0.9; I2 = 0%).
Age 50 years. Two articles [
] reported the relationship between age at surgery
(<50 or 50) and complications after RM. The test for heterogeneity was not significant (p for
heterogeneity = 0.74; I2 = 0%). The aggregated results of the 2 studies suggest that age 50
years was not associated with a significant increase in the overall incidence of complications
after RM (OR 0.96; 95% CI: 0.71±1.29, p = 0.78) (Fig 4).
TRW 1000 g. Two articles [
] reported the relationship between TRW (<1000 g or
1000 g) and complications after RM. The test for heterogeneity was significant (p for
heterogeneity = 0.16; I2 = 50%). Using the random-effect model, the aggregated results suggest that
TRW 1000 g was not associated with a significant increase in the overall incidence of
complications after RM (OR 1.04; 95% CI: 0.43±2.50, p = 0.93) (Fig 5).
Smoking status. We combined 6 studies [6, 14, 18, 20±22] concerning smoking and
complications after breast reduction. The test for heterogeneity was significant (p for
5 / 13
Schumacher HH et al. 39.0
Cunningham BL et al. 39.4
Chan LK et al. 2006[
Bikhchandani J et al. 34.3
Kendall R et al. 2008 35.0
Setala L et al. 2009[
Shah R et al. 2011[
Chun YS et al. 2012[
Roje Z et al. 2012[
Deliaert AE et al. 2012 35.9
Nelson JA et al. 2014 NR
Nelson JA et al. 2014 43.2
Guemes A et al. 2015 40.7
Dal Cin A et al. 2012[
Parrett et al. 2010[
Weichman KE et al. 50.2
IP:63.3; VS:4.1;SP:29.0; FNG:3.6
IP:74.9; VS:4.5; FNG:20.6
IP:10.2; VS:72.9; SP:10.2; FNG:6.7
IP:46.0; VS:8.2; SP:5.0; FNG:5.1; MP:10.0;
BMI: body mass index; NR: not reported; IP: inferior pedicle; VS: vertical scar; SP: superomedial pedicle; FNG: free nipple graft; MP: medial pedicle; CMT:
central mound technique
heterogeneity = 0.13; I2 = 41%). Using the random-effect model, the aggregated results
suggest that smoking was highly associated with a significant increase in the overall incidence of
complications (OR 1.56; 95% CI: 0.98±2.49, p = 0.06) (Fig 6). In addition, smoking was also
highly associated with a significant increase in the incidence of wound dehiscence after RM
of 4 studies [
5, 6, 19, 24
] (OR 2.73; 95% CI: 1.60±4.67, p = 0.0002) (Fig 7). The test for
heterogeneity was not significant (p for heterogeneity = 0.75; I2 = 0%).
Fig 2. Correlations between BMI and complications.
6 / 13
Fig 3. Correlations between BMI and infections.
Fig 4. Correlations between age and complications.
Fig 5. Correlations between tissue resection weight per breast and complications.
Radiation therapy. We finally selected 3 studies [25±27] reporting radiation therapy and
complications after RM. The test for heterogeneity was not significant (p for
heterogeneity = 0.46; I2 = 0%). The aggregated results suggest that breast reduction after radiation lead to
a significant increase in the incidence of infection (OR 20.38; 95% CI: 3.42±121.35, p = 0.0009)
(Fig 8). However, the fat necrosis after RM was not significant between irradiated and
nonirradiated breasts (OR 2.51; 95% CI: 0.35±18.12, p = 0.36) (Fig 9). The test for heterogeneity was
not significant (p for heterogeneity = 0.41; I2 = 0%).
Fig 6. Correlations between smoking and complications.
7 / 13
Fig 7. Correlations between smoking and wound dehiscence.
Fig 8. Correlations between radiation and infection.
For observational studies, we applied the Risk of Bias Assessment tool for Nonrandomized
Studies (RoBANS), which was compatible with the Cochrane risk-of-bias tool.
Even though women undergoing breast reduction were generally young and healthy,
postoperative complications were relatively common, with an incidence of 14%-53% in reported
6, 17, 28
], of which the risk factors associated with complications after RM were
controversial, so we performed a meta-analysis to evaluate the important risk factors.
Increased BMI was the strongest predictor of complications among patients with breast
reduction in our meta-analysis. The patients' weights were categorized as follows: a BMI equal
to or less than 18.5 kg/m2 was classified as ªunderweightº; a BMI between 18.5 and 24.99
kg/m2 was ªnormal weightº; a BMI between 25 and 29.99 kg/m2 was ªoverweightº and a BMI
of 30 kg/m2 or more was ªobeseº (in line with the WHO general classification of obesity) [
Based on their BMIs, the patients were divided into two groups (underweight, normal, and
overweight formed the ªnon-obeseº group; the remainder comprised the ªobeseº group) [
The vast majority of studies concluded that breast reduction surgery in the obese population
had a significantly higher rate of complications than in the nonobese population [
although there was some evidence to the contrary [
11, 23, 30
]. One significant limitation with
Fig 9. Correlations between radiation and fat necrosis.
8 / 13
the majority of these studies, however, was that they were mostly single institution case series
with homogeneous patient populations . Our assumption that surgical technique might be
the biggest element resulted in contrary conclusions in different studies. What is more, the
results of our meta-analysis indicated that obese patients were more likely to experience
complications, especially infection, than the nonobese, which was based on a large number of
patients. On a biological level, the relative vascularity of adipose tissue makes this tissue more
vulnerable to infection. Obese women have been shown to have impaired capillary recruitment
and acetylcholine-mediated vasodilation [
]. In addition, obese individuals have significantly
increased transepidermal water loss and erythema compared to controls [
]. Our results
suggest that full disclosure of high postoperative complication rates in patients with a higher BMI
is essential and that they should also be well informed that the chances of infection are also
higher than in nonobese patients. If avoidable, breast reduction surgery should not be
performed on obese patients unless they lose weight.
Our mate-analysis demonstrated that age at surgery 50 years bears no relationship to
complications in RM compared with younger patients <50 years. According to a positive
study by Shermak MA et al.[
], we divided the patients into two groups with a boundary of
50 years. In fact, Shermak MA et al.[
] put forward that age older than 50 years impaired
breast reduction outcomes, particularly infection, and might negatively impact wound healing.
However, Nelson JA et al.[
] suggested that RM could be performed safely on older patients
with proper patient selection. This assertion is supported by other studies [
results were similar to ours. The results of this meta-analysis suggest that RM can be safely
performed on elderly patients. However, patients with severe comorbidities or high BMI should
not be admitted, whether young or old. Therefore, appropriate patient selection and
counseling are essential before surgery.
TRW 1000 g was not a significant factor in the overall incidence of complications
compared with smaller resections. We had arbitrarily set the crossover point between small and
large reductions at 1000 g of tissue per breast [
]. Zubowski R et al.[
] determined that the
likelihood of developing complications increased linearly as the reduction size increased, and
Dabbah A et al.[
] noted that there was a considerable increase in the number of complications
when reductions over 1000 g per breast were performed. Similar results were found by Shah R
] and Cunningham BL et al.[
]. In contrast, Roje Z et al.[
] concluded that there was
no significant relationship between patient complications and resection weight of breast
parenchyma. Our meta-analysis with a large sample size implied that surgeons might properly
finish the RM procedure to relieve a patients' extreme symptoms, and omitted mentioning
how much tissue was resected. However, more resection than average was not admitted in
order to maintain aesthetics.
Another strong risk factor for complications after RM in our meta-analysis was smoking.
Many other studies supported our results of the effect of smoking status on complication rates,
such as Schumacher HH et al.[
], Roje Z et al.[
] and others. However, Kendall R et al.[
found no statistically significant increase in complications in smokers, as did Cunningham BL
] and Guemes A et al.[
]. We suspected that their definition of smokers was different,
which might have brought about different results. Furthermore, our results indicated that
smokers had higher rates of experiencing wound dehiscence than did nonsmokers.
Woundhealing problems were the most frequent complications among smokers according to previous
5, 19, 24
]. Smoking contributed a thrombogenic state, induced endothelial wall
damage, inhibited capillary blood flow, and released catecholamines, which were responsible for
]. In conclusion, our results implied that it was important to stop smoking
before breast reduction surgery to reduce complication rates. We suggest that it is better to
quit smoking for 6 months or more before surgery and a shorter time might be ineffective.
9 / 13
Although smoking was significant for complications in our meta-analysis (p = 0.06),
heterogeneity was also significant (I2 = 41%), so we used the random-effect model and sensitivity
analysis to evaluate the source of high heterogeneity. The results of sensitivity analysis showed
that smoking was also highly associated with complications (p = 0.02) with a low heterogeneity
(I = 0%) when excluding one study of Roje Z et al.[
]. We systematically and comprehensively
assessed the study characteristics, patient and treatment characteristics and any differences
from five other studies [
6, 14, 18, 20, 21
], but found no source of heterogeneity for the excluded
study. It was reasonable for us to believe that the result was credible because it was strongly
supported by available evidence.
Radiation therapy increased the postoperative infection rates, but it was not associated with
fat necrosis in our meta-analysis. Several investigators had reported significantly increased
rates of complications in patients treated with radiation, and some, including Dal Cin A et al.
] and Parrett BM et al.[
], considered radiation therapy a contraindication to RM. We
presumed that it was due to the known harmful effects of radiation. However, some recent
researches implied that the postoperative complications were similar in both irradiated and
nonirradiated breasts. For example, Weichman KE et al.[
] suggested that RM could be
performed safely after irradiation. We hypothesized it may be attributed to their surgical
procedure of central mound technique. In conclusion, what our meta-analysis suggests is that RM
should not be performed on irradiated patients unless they are carefully selected. The central
mound technique might be a good choice for surgeons.
In this meta-analysis, we rudimentarily understood which population was more likely to
have complications after breast reduction, how we developed a better surgical strategy before
operating, what we focused on intraoperation and what measures should be taken to minimize
the occurrence of postoperative complications. This was preliminary a guidance for selecting
patients of RM treatment. As a minimum, it helped pave the way, for future studies of
We recognized several limitations in our study. First, some factors, such as preoperative
breast volume, nipple elevation, surgical techniques and diabetes mellitus, which might be
post-RM risk factors for complications were not analyzed because related studies were few and
we could not reach a pooled result. Second, many possible risk factors (such as techniques) are
not mutually exclusive, which might have led to overestimating a complication risk. This study
was not designed to provide independent risk factors for complications, for the reporting data
was insufficient to do a multivariate analysis. Third, this meta-analysis was an observational
study so that a randomized controlled trial was necessary. However, performance of any such
study would be difficult. Consequently, there was marked heterogeneity among risk factors. So
we attempted to account for heterogeneity using a random-effect model for meta-analysis
when the Cochran Q statistic was significant, and find the source of high heterogeneity using
sensitivity analysis. Finally, perhaps the biggest limitation of this meta-analysis and an
important target for future research was the inability to perform outcome subgroup analyses by
This meta-analysis demonstrated that BMI 30 kg/m2 and smoking status are risk factors for
complications after RM. Moreover, BMI 30 kg/m2 and radiation therapy showed a
statistically higher incidence of infection and smokers acquired higher significant rates of wound
dehiscence. However, age 50 years and TRW 1000 g are not associated with post-RM
complications. Further large-scale, well-designed studies are urgently needed.
10 / 13
S1 File. PRISMA 2009 flow diagram.
S2 File. PRISMA 2009 checklist.
The authors are grateful to Li-Gen Shi, from department of neurosurgery, the Second
Affiliated Hospital, School of Medicine, Zhejiang University, China, for his advice on the
Conceptualization: MZ WT.
Data curation: MZ CC.
Formal analysis: MZ CC QF JX.
Funding acquisition: WT.
Methodology: MZ CC QF JX.
Software: MZ XW.
Validation: MZ WT.
Writing ± original draft: MZ XW BS LW.
Writing ± review & editing: MZ WT.
11 / 13
Wagner DS, Alfonso DR. The influence of obesity and volume of resection on success in reduction
mammaplasty: an outcomes study. Plast Reconstr Surg. 2005; 115: 1034±1038. PMID: 15793442
12 / 13
1. Davis GM , Ringler SL , Short K , Sherrick D , Bengtson BP . Reduction mammaplasty: long-term efficacy, morbidity, and patient satisfaction . Plast Reconstr Surg . 1995 ; 96 : 1106 ± 1110 . PMID: 7568486
2. Schnur PL , Schnur DP , Petty PM , Hanson TJ , Weaver AL . Reduction mammaplasty: an outcome study . Plast Reconstr Surg . 1997 ; 100 : 875 ± 883 . PMID: 9290655
3. Dabbah A , Lehman JA , Parker MG , Tantri D , Wagner DS . Reduction mammaplasty: an outcome analysis . Ann Plast Surg . 1995 ; 35 : 337 ± 341 . PMID: 8585673
4. Brown A , Hill C , Khan K. Outcome of reduction mammaplastyÐa patients' perspective . Br J Plast Surg . 2000 ; 53 : 584 ± 587 . doi: 10 .1054/bjps. 2000 .3380 PMID: 11000075
5. Chan LK , Withey S , Butler PE . Smoking and wound healing problems in reduction mammaplasty: is the introduction of urine nicotine testing justified? Ann Plast Surg . 2006 ; 56 : 111 ± 115 . doi: 10 .1097/01.sap. 0000197635 .26473.a2 PMID: 16432315
6. Cunningham BL , Gear AJ , Kerrigan CL , Collins ED. Analysis of breast reduction complications derived from the BRAVO study . Plast Reconstr Surg . 2005 ; 115 : 1597 ± 1604 . PMID: 15861063
7. Baldwin CJ , Kelly EJ , Batchelor AG . The variation in breast density and its relationship to delayed wound healing: a prospective study of 40 reduction mammoplasties . J Plast Reconstr Aesthet Surg . 2010 ; 63 : 663 ± 665 . doi: 10 .1016/j.bjps. 2009 . 06 .001 PMID: 19628440
8. Henry SL , Crawford JL , Puckett CL . Risk factors and complications in reduction mammaplasty: novel associations and preoperative assessment . Plast Reconstr Surg . 2009 ; 124 : 1040 ± 1046 . doi: 10 .1097/ PRS.0b013e3181b45410 PMID: 19935287
9. Platt AJ , Mohan D , Baguley P. The effect of body mass index and wound irrigation on outcome after bilateral breast reduction . Ann Plast Surg . 2003 ; 51 : 552 ± 555 . doi: 10 .1097/01.sap. 0000095656 .18023. 6b PMID: 14646646
10. Chen CL , Shore AD , Johns R , Clark JM , Manahan M , Makary MA The impact of obesity on breast surgery complications . Plast Reconstr Surg . 2011 ; 128 : 395e± 402e . doi: 10.1097/PRS. 0b013e3182284c05 PMID: 21666541
11. Setala L , Papp A , Joukainen S , Martikainen R , Berg L , Mustonen P , et al. Obesity and complications in breast reduction surgery: are restrictions justified? . J Plast Reconstr Aesthet Surg . 2009 ; 62 : 195 ± 199 . doi: 10 .1016/j.bjps. 2007 . 10 .043 PMID: 18039601
12. Gamboa-Bobadilla GM , Killingsworth C . Large-volume reduction mammaplasty: the effect of body mass index on postoperative complications . Ann Plast Surg . 2007 ; 58 : 246 ± 249 . doi: 10 .1097/01.sap. 0000248108 .52837.6c PMID: 17471126
14. Kendall R , Craig ES , Gomez V , Phillips LG . Breast reduction: Safe in the morbidly obese? . Plast Reconstr Surg . 2008 ; 122 : 370 ± 378 . doi: 10 .1097/PRS.0b013e31817d60f4 PMID: 18626352
15. Nelson JA , Fischer JP , Wink JD , Kovach SJ . A population-level analysis of bilateral breast reduction: does age affect early complications? Aesthet Surg J . 2014 ; 34 : 409 ± 416 . doi: 10 .1177/ 1090820X14525393 PMID: 24604788
16. Xiao SW , Jiang H , Yang LJ , Xiao ZM . Anterior cervical discectomy versus corpectomy for multilevel cervical spondylotic myelopathy: a meta-analysis . Eur Spine J . 2015 ; 24 : 31 ± 39 . doi: 10 .1007/s00586-014 - 3607-1 PMID: 25326181
17. Shah R , Al-Ajam Y , Stott D , Kang N. Obesity in mammaplasty: a study of complications following breast reduction . J Plast Reconstr Aesthet Surg . 2011 ; 64 : 508 ±514 doi: 10.1016/j.bjps. 2010 . 07 .001 PMID: 20682461
18. Chun YS , Schwartz MA , Gu X , Lipsitz SR , Carty MJ . Body mass index as a predictor of postoperative complications in reduction mammaplasty . Plast Reconstr Surg . 2012 ; 129 : 228e± 233e . doi: 10.1097/ PRS.0b013e31823ae949 PMID: 22286438
19. Bikhchandani J , Varma SK , Henderson HP . Is it justified to refuse breast reduction to smokers? . J Plast Reconstr Aesthet Surg . 2007 ; 60 : 1050 ± 1054 . doi: 10 .1016/j.bjps. 2007 . 01 .073 PMID: 17512812
20. Schumacher HH . Breast reduction and smoking . Ann Plast Surg . 2005 ; 54 : 117 ± 119 . PMID: 15655457
21. Nelson JA , Fischer JP , Chung CU , West A , Tuggle CT , Serletti JM , et al. Obesity and early complications following reduction mammaplasty: an analysis of 4545 patients from the 2005±2011 NSQIP datasets . J Plast Surg Hand Surg . 2014 ; 48 : 334 ± 339 . doi: 10 .3109/2000656X. 2014 .886582 PMID: 24506446
22. Roje Z , Roje Z , Milosevic M , Varvodic J , Mance M. Current trends in breast reduction . Coll Antropol . 2012 ; 36 : 657 ± 668 . PMID: 22856260
23. Guemes A , Perez E , Sousa R , Gil I , Valcarreres MP , Carrera P , et al. Quality of Life and Alleviation of Symptoms After Breast Reduction for Macromastia in Obese Patients: Is Surgery Worth It? Aesthetic Plast Surg . 2015 ; 40 : 62 ± 70 . doi: 10 .1007/s00266-015-0601 -x PMID : 26718700
24. Deliaert AE , Van den Kerckhove E , Tuinder S , Noordzij SM , Dormaar TS , Van der Hulst RR . Smoking and its effect on scar healing . Eur J Plast Surg . 2012 ; 35 : 421 ± 424 . doi: 10 .1007/s00238-011 -0661-3 PMID: 22661831
25. Dal Cin A , Knight C , Whelan KF , Farrokhyar F . Bilateral reduction mammoplasty following breast cancer: A case-control study . Can J Plast Surg . 2012 ; 20 ( 1 ):e6± e9 . PMID: 23598771
26. Parrett BM , Schook C , Morris D . Breast reduction in the irradiated breast: evidence for the role of breast reduction at the time of lumpectomy . Breast J . 2010 ; 16 ( 5 ): 498 ± 502 . doi: 10 .1111/j.1524- 4741 . 2010 . 00965 . x PMID : 21054644
27. Weichman KE , Urbinelli L , Disa JJ , Mehrara BJ . Breast reduction in patients with parior breast irradiation: outcomes using a central mound technique . Plast Reconstr Surg . 2015 ; 135 ( 5 ): 1276 ± 1282 . doi: 10 .1097/PRS.0000000000001147 PMID: 25919242
28. Roehl K , Craig ES , GoÂmez V , Phillips LG . Breast reduction: safe in the morbidly obese? . Plast Reconstr Surg . 2008 ; 122 : 370 ± 378 . doi: 10 .1097/PRS.0b013e31817d60f4 PMID: 18626352
29. BMI classification. World Health Organization. http://apps.who.int/bmi/index.jsp?introPage=intro_3. html.
30. Dafydd H , Roehl KR , Phillips LG , Dancey A , Peart F , Shokrollahi K. Redefining gigantomastia . J Plast Reconstr Aesthet Surg . 2011 ; 64 : 160 ± 163 . doi: 10 .1016/j.bjps. 2010 . 04 .043 PMID: 20965141
31. Yosipovitch G , DeVore A , Dawn A . Obesity and the skin: skin physiology and skin manifestations of obesity . J Am Acad Dermatol . 2007 ; 56 : 901 ± 916 . doi: 10 .1016/j.jaad. 2006 . 12 .004 PMID: 17504714
32. Shermak MA , Chang D , Buretta K , Mithani S , Mallalieu J , Manahan M. Increasing age impairs outcomes in breast reduction surgery . Plast Reconstr Surg . 2011 ; 128 : 1182 ± 1187 . doi: 10 .1097/PRS. 0b013e318230c467 PMID: 22094737
33. O 'Grady KF , Thoma A , Dal Cin A. A comparison of complication rates in large and small inferior pedicle reduction mammaplasty . Plast Reconstr Surg . 2005 ; 115 : 736 ± 742 . PMID: 15731672
34. Zubowski R , Zins JE , Foray-Kaplon A , Yetman RJ , Lucas AR , Papay FA , et al. Relationship of obesity and specimen weight to complications in reduction mammaplasty . Plast Reconstr Surg . 2000 ; 106 : 998 ± 1003 . PMID: 11039370
35. Su C . Actions of nicotine and smoking on circulation . Pharmacol Ther . 1982 ; 17 : 129 ± 141 . PMID: 6138786