When I saw the title of this journal article I wasn’t going to read it. “Breast Hypertrophy: A Real Pain in the Back.” in the March 2023 Plastic and Reconstructive Surgery Journal. But I had a few moments, so I read the synopsis, and this really caught my eye.
Conclusion, “Quality of life scores are uniformly improved following breast reduction. Key findings include significant pain reduction and no evidence of spinal skeletal change. This is a finding of major importance in view of the practice of many insurance companies that use the Schnur scale. The Schnur scale associates a weight for resection with body size that is not directly predictive of pain relief. This may indicate the need for more precise or different guidelines based on these quantitative findings.”
Can we, should we, boot the Schnur scale?
I do tons of breast reductions. It is clear that they help all women. Period. It helps women who droop, and women who stoop. It helps those with big double Ds or smaller breasts that tickle your knees. There are two basic things to fix: SIZE/WEIGHT and DROOP.
- This was a prospective, cohort study. They did pre and post surgery questionnaires, MRIs, and spinal scans.
- They only did short scar lollipop reductions (GO TEAM!)
- They argue that large breasts do a number on the spine: they looked at paraspinal muscles, vertebrae, the spine disks, tendons, and ligaments which create an upright spine.
- They looked at the quantitative effects of muscle mass to hold up those large breasts (MRI evaluation)
- 25 women cohort matched. age 18-70, minimum reduction of 250g/breast, no prior spinal issues/trauma, mean BMI 28.
FINDINGS:
- Statistically significant different in neck, back and lumbar pain
- THE IMPROVEMENT WAS NOT INFLUENCED BY THE AMOUNT OF TISSUE REMOVED
- ODI showed statistically significant reduction in disability caused by back pain and improvement in overall health
- The questionnaire showed statistically significant postop improvement in psych well being, sexual well being, and physical well being.
- Physical exercise parameters statistically significantly improved: plank time, flights of stairs climbed
- Statistically significant improvement in kyphosis (hunchback) of 5-6 degrees.
- There was no difference seen in muscles of the area.
- SYMPTOM RESULTS WERE QUICK . What was seen at 2 weeks was similar to what was seen at 6 months.
- EVEN A 250 GRAM REDUCTION RESOLVED BACK PAIN CLINICALLY.
They conclude breast reductions are awesome and should not be considered by the amount of tissue removed. Pain, posture, kyphosis, exercise tolerance, etc etc were all better. They use the MRI to refute “wear and tear” of the spine- so when patients do the breast reduction, they revert to a more neutral posture and REVERSE the skeletal changes.
My thoughts?
We have to ditch the Schnur scale to show “medical necessity.” Small reductions can cause significant improvement. Droop is as much of an issue for all the medical symptoms as the weight is. Small reductions for sure improve back pain, neck pain, ability to exercise, and self esteem.
The Schnur scale is sometimes ridiculous, requiring some of my patients to have large++ gram breast reductions, so big we couldn’t safely do that amount of gram reduction and still have a breast or a viable nipple. Some require removal of a weight which is equal to the total size of the breast (like doing a mastectomy!).
And again, it does. not. correlate. with. symptom. improvement.
I hope this study makes some traction with insurance coverage.