Introduction

Women with breast hypertrophy often exhibit one or more of the following symptoms: uncomfortable feeling about their body, neck pain, back pain, shoulder pain, bra-strap grooving, intertrigo, inability to run or to participate in sports, headaches, and pain or numbness in the hands [1]. Conservative measures such as weight loss, physical therapy, special brassieres, and medications are encouraged by the health care insurers but often do not produce permanent relief of symptoms [2].

There is an ongoing debate about the medical necessity of surgical therapy, but it remains the only option for women with macromastia who have tried the aforementioned conservative measures and did not get the attributed benefits [3, 4]. Besides, surgery proves effective not only for patients with a normal body mass index (BMI) but also for obese patients regardless of the weight of the tissue resected [2, 5].

Although surgical intervention is supposed to be a safe and highly effective solution for breast hypertrophy, measures used for evaluating the outcomes of breast reduction surgery are mostly subjective. Questionnaires and pain scales are widely used for this purpose, and significant improvements have been demonstrated including decreased head and neck pain, shoulder pain, shoulder grooving, and analgesic use, as well as improvement in activity level and self-image [1, 6].

Only a few studies have aimed to demonstrate the objective outcomes after breast reduction surgery. Among them, the studies seeking a correlation between breast reduction surgery and improvement in pulmonary functions have reported controversial results [7, 8]. In addition, a recent report has demonstrated objective improvement in low back compressive forces after reduction mammaplasty for patients with macromastia [9].

The mechanism of breast hypertrophy-induced neck pain, back pain, and shoulder grooving is obvious and mostly posture related. Breast reduction surgery seems to address this problem by reducing the postural disability and further alleviating the mentioned symptoms.

The background for this study was observation of the patients’ postoperative relief of restraints during “mild” daily activities.

We hypothesized that breast reduction surgery would result in improved body posture of the patient while walking. This study was designed to evaluate the dynamic postural changes after reduction mammaplasty for the first time using three-dimensional quantitative gait analysis.

Materials and Methods

Participants and Study Design

Women with breast hypertrophy seeking surgery were asked to participate in this study with its prospective repeated measures design. The participants were otherwise healthy women determined to be candidates for surgery by our clinical committee. Each woman signed a consent form. Women were excluded from the study if they had any pathology of the spine or lower extremities limiting regular walking or had any concomitant systemic medical condition that was a contraindication for major surgery.

Gait Analysis

Three-dimensional quantitative gait analysis was performed for each patient before surgery and 2 months afterward. We gathered kinematic data using a seven-camera Vicon Motion Analysis System (Vicon, Centennial, CO, USA). The procedure was launched after equipment setup and patient preparation. Before entry of participants into the laboratory, static and dynamic calibration of the system was performed.

During subject preparation, anthropometric data including height, weight, leg length, and joint width of the knee and ankle were collected. Each participant used bathing slips to achieve standardization of the specific anatomic landmarks on which the passive reflective markers were placed.

After confirmation that the infrared cameras visualized all 33 retroreflective markers, patients were asked to walk on the platform barefoot at a self-selected pace a number of times over a 10-m-long walkway, during which time data collection was completed (Fig. 1 left, right). Seven cameras recorded the quantitative spatial location of each marker as the subject walked. The trial in which the system automatically and clearly identified all markers was determined as supplying the best data. After joint kinematic graphs in all three planes during the gait cycle had been obtained, interpretation of the data was performed by a specialist well-trained and experienced in physical and rehabilitation medicine.

Fig. 1
figure 1

Left Anterior view of the patient with reflective markers. Right Posterior view of the patient on the platform

Full size image

Statistical Analysis

Statistical data were imported into SPSS 15 for Windows (SPSS, Chicago, IL, USA). Pre- to postsurgical differences between spine and lower extremity kinematic data were analyzed using the two-tailed nonparametric Wilcoxon signed ranks test (p < 0.05).

Results

Participants

The study participants consisted of 11 women who met the inclusion criteria. Of these 11 women, 10 completed the study. The women had an average age of 44.2 years (range, 34–65 years), and an average body mass index (BMI) of 29.2 kg/m2 (range, 25–34 kg/m2) (Table 1). The mean follow-up period was 8 months (range, 2–16 months).

Table 1 Age, body mass index, and resected tissue weight of each patient’s right and left breasts
Full size table

Reduction mammaplasty was performed by one of three plastic surgeons using the vertical scar superomedial pedicle (estimated tissue excision amount, <500 g) for five patients, the inverted T-scar inferior pedicle (estimated tissue excision amount, 500–1,000 g) for three patients, and free areola grafting (estimated tissue excision amount, >1,000 g) for two patients. The weight of the total tissue removed from both breasts ranged from 910 to 3,410 g (mean, 1,693 g) (Table 1).

Kinematic Data

The participants demonstrated a 41 % reduction in the average maximum anterior pelvic tilt angle (angle between the vertical axis of the pelvis and a vertical line). The preoperative mean (minimum–maximum) value was 16.7 (range, 11.5–20.1), and the postoperative mean (minimum–maximum) value was 11.8 (range, 6.5–14.2; p = 0.011). We also found a 30 % reduction in the average maximum spine anterior flexion angle (angle between the lumbar vertebrae and a vertical line) from pre- to postoperative measurements. The preoperative mean (minimum–maximum) value was 13.1 (range, 9.3–15.3), and the postoperative mean (minimum–maximum) value was 9.3 (range, 6.0–14.5; p = 0.011). All the kinematic data are given in Table 2.

Table 2 Three-dimensional gait analysis data
Full size table

Analysis of the kinematic data showed no significant difference in ankle (dorsal and plantar flexion), knee (flexion and extension), and hip (adduction/abduction, flexion/extension, and internal/external rotation) joint angles, demonstrating almost similar walking strategies for each individual between the pre- and postoperative tests (p > 0.05).

Discussion

Undoubtedly, women undergoing reduction mammaplasty to remove the unbearable burden of their large breasts usually are highly satisfied with the outcomes. However, appraisal of the surgical outcomes has been done mostly by using subjective measures. There is the high patient satisfaction rate on one hand and the lack of objective evidence on the other hand. As an objective tool, pulmonary function tests have been used, often with controversial results [7, 8].

Foreman et al. [9] examined the impact of surgery on low back compressive forces using a “motion” analysis system. For a given task (lifting a 5-lb weight to a 16-in. height from the floor), low-back compressive forces were measured before surgery and 3 months afterward. Although the kinematic and kinetic parameters of the hip, knee, and ankle joints did not show a significant difference, postsurgical low back compressive forces were reduced significantly compared with the presurgical measurements. This was interpreted as a decreased risk for disc degeneration and low back disorders. The authors also stated that their results warrant additional research for prospective investigation of these individuals.

In our study, we aimed to investigate the motion of the vertebral column during regular walking. The focus of the current study was on the joints’ active range of motion, so we used kinematic measurements.

The participants demonstrated a 41 % reduction in the average maximum anterior pelvic tilt angle and a shift toward a more normal range from the preoperative abnormal values. Anterior pelvic tilt actually is a quite normal postural position that helps to control the body’s center of gravity in the sagittal plane and constitutes the base for lumbar lordosis. The ideal anterior pelvic tilt values are 0°–5° for men and 7°–10° for women.

Herrington [10] measured the anterior pelvic tilt angle in 120 normal asymptomatic healthy subjects and found that 85 % of males and 75 % of females have an anteriorly rotated pelvis, with an average range of 6°–7° among both sexes. When the anterior pelvic tilt angle increases, the arch in the lower back increases significantly, and the same happens in the neck. We can say that all our patients had faulty body postures before the operation.

Faulty posture, one of the most important reasons for low back pain, is related to multiple musculoskeletal pathologies. Shirley stated that this is related to the position of the pelvis [11]. Although the mechanism of the pathology is unclear, the potential mechanism is the changing of the biomechanical stress on the musculoskeletal system.

Based on our findings, it can be speculated that breast reduction surgery renders control of the body’s center of gravity easy and affects the patient’s posture in a positive manner while walking. Improvement in body posture may be the most effective reason for relief of symptoms, which can be comparable with low back pain seen in pregnancy [12].

The participants also demonstrated a 30 % reduction in the average maximum spine anterior flexion angle. Considered with the aforementioned enhancements, it shows an overall backward change in the patient’s body posture while walking. These two relatively early changes regarding body posture correlate with the subjective relief in patients from shoulder, neck and back pain.

We observed that the degree of improvement in the anterior pelvic tilt and anterior spine flexion is numerically higher for patients from whom more breast tissue was resected than for patients who had less tissue resected. But we could not assess this finding statistically and could not relate the type of technique or excised tissue amount with the degree of improvement due to the low number of patients.

Women who underwent breast reduction surgery demonstrated no significant difference in hip, knee, or ankle joint kinematic parameters between the pre- and postoperative measurements. Gait analysis predominantly uses these three joints of the lower extremity. The gait cycle of each individual is unique in its nature and established in the early years of life without the existence of a major trauma or congenital disease. It rarely is affected by secondary means including major surgery above the pelvis unless a neurologic complication occurs. Therefore, the fact that breast reduction surgery did not affect the kinematic parameters of the lower extremity correlates with previous knowledge.

This study had some major drawbacks worthy of mention. We had a limited number of participants with different ages and diverse breast sizes, which rendered the findings inconvenient for generalization to all women with breast hypertrophy.

In addition, due to variable body mass indices and resection weights, it may not be feasible to seek a correlation between breast size, body weight, and gait analysis results. However, Spector et al. [5] found that the symptomatic improvement derived from reduction mammaplasty did not differ significantly between women of varied breast sizes and amounts of tissue resected. Further research with a larger participant population will be of greater value in addressing these problems. However, given the minimum BMI of 25 kg/m2 and the lack of significant change in body weight after surgery, we may conclude that even overweight patients benefited from the surgery. Because the patients undergoing breast reduction mostly express their satisfaction and relief of symptoms in the early postoperative period, we performed the second gait analysis 2 months after surgery.

Conclusions

Breast reduction surgery is renowned for its high patient satisfaction rates compared with those of other cosmetic procedures. Despite this fact, there is a shortage of objective tools to validate the results. To our knowledge, reduction mammaplasty outcomes were evaluated for the first time by three-dimensional quantitative gait analysis in the current study. According to our findings, breast reduction surgery resulted in improved body posture of the patient while walking, and this represented objective evidence supporting the claim that it is both a functional and a cosmetic surgery.