University of Southern Denmark Poor adherence to clinical guidelines for women undergoing breast reduction Aydin,

INTRODUCTION: Indication for breast reduction in a public­ ally funded or an insurance­funded setting depends on the severity of the subjective symptoms and on the clinical evalu ation. The purpose of this study was to evaluate whether Danish surgeons follow a clinical practice recom­ mending a minimum tissue resection weight of 400­500 g per breast. METHODS: Included in the study were a total of 366 female patients with breast hypertrophy who underwent bilateral breast reduction surgery at three large university hospitals in Denmark in the period from August 2008 to November 2013. The patients’ height, weight and standard breast measure­ ment were registered as was the weight of breast tissue re­ section. The preoperative breast volume was measured us­ ing transparent plastic cups designed for this purpose. RESULTS: Among the 366 female participants, the median age was 40 years, the median BMI was 24 kg/m2, and the median breast volume was 1,050 cc on each side. Only 201 (55%) cases met the resection criterion of a minimum of 400 g tissue per breast, and 130 (36%) had 500 g or more resected. We found a highly significant correlation between the amount of resected breast tissue and the preoperative breast volume (p < 0.001, n = 366). CONCLUSIONS: Many surgeons did not follow the clinical practice of resecting 400­500 g of breast tissue in women who underwent breast reduction surgery at three large hos­ pitals in Denmark in the 2008­2013 period. Our findings are surprising and beg the question if the guidelines should be revised to reflect the current practice or vice versa. FUNDING: none. TRIAL REGISTRATION: not relevant. Breast reduction surgery is a common and successful surgical treatment for shoulder/neck pain, bra­strap grooving, back pain and headache due to breast hyper­ trophy [1, 2]. Several studies have also shown improved quality of life and improvement in psychosocial symp­ toms after breast reduction surgery [3, 4]. To be oper­ ated in a publicly financed healthcare system such as those of the Scandinavian countries, patients seeking breast reduction must present with adequate functional problems and not only with cosmetic concerns [5]. To distinguish cases that are based primarily on cosmetic complaints from those based on functional complaints, a woman requesting breast reduction surgery in Denmark must, as in most other countries, express relevant phys­ ical symptoms, preferably be 18 years of age or more, and shall generally have a body mass index (BMI) below 25 kg/m2. According to standard clinical practice, the breast volume must be of a size that allows resection of at least 400­500 g on each side. [5­8]. This is based not on a national guideline, but on local clinical practices [7, 8], which are quite similar over the country (exceptions from these demands are occasionally allowed; for in­ stance, if the woman has co­morbidity, short stature, ser ious gigantomastia, etc.) Furthermore, to some ex­ tent the following measurements may also be used for evaluation: sternal notch­to­nipple distance (NND), pto­ sis (distance from the lower pole of the breast to the sub­mammary fold) and chest circumference. In a previ­ ous study [5], we evaluated the feasibility of measuring preoperative breast volume using special plastic cups, and the pre­operative volume was correlated to the de­ cision of offering breast reduction surgery. This previous study was undertaken in recognition of the need for a more objective criterion for the decision to perform breast reduction surgery. In three departments of plastic surgery in Eastern Denmark, we found full agreement that, in general, women with relevant complaints who fulfilled the inclusion criteria were offered reduction sur­ gery if they had a breast volume of 900 cc or more, while women with a breast volume of less than 800 cc were denied surgery [5]. The aim of the present study was to evaluate whether surgeons actually comply with the clinical practice [7, 8] stipulating a minimum tissue resection weight of 400­500 g per breast.