|Year : 2018 | Volume
| Issue : 2 | Page : 62-66
The effects of breast reduction on sexual activity
Meltem Ayhan Oral1, Cem Aslan2, Murat Tuzuner1, Ersin Aksam1, Fatma Buse Kilin Capkinoglu3, Demet Gulpek4
1 Department of Plastic Reconstructive and Aesthetic Surgery, Izmir Katip Celebi University, Ataturk Training and Research Hospital, Izmir, Turkey
2 Department of Plastic Reconstructive and Aesthetic Surgery, Giresun University, Giresun, Turkey
3 Department of Plastic Reconstructive and Aesthetic Surgery, Adana City Hospital, Adana, Turkey
4 Department of Psychiatry, Izmir Katip Celebi University, Ataturk Training and Research Hospital, Izmir, Turkey
|Date of Web Publication||13-Apr-2018|
Dr. Ersin Aksam
Department of Plastic Reconstructive and Aesthetic Surgery, Ataturk Training and Research Hospital, Izmir Katip Celebi University, Izmir
Source of Support: None, Conflict of Interest: None
Background: Patients with macromastia sometimes claim that their sexual life is negatively affected from the hypertrophic breasts. The intention of this prospective study is to evaluate the effects of breast reduction surgery on sexual satisfaction, marital adjustment, and the psychological condition of patients. Materials and Methods: The experimental group (n = 25) consisted of patients who had undergone surgery for macromastia, while the control group (n = 23) consisted of matched patients with similar demographic features. Using questionnaires, the respondents from the experimental group were evaluated for their body image perception, self-esteem, anxiety and depression status, sexual satisfaction, and marital adjustment both before surgery and 12 months after surgery. The same questionnaires were administered to the patients in the control group. Results: A comparison of the pre- and postoperative scores from the questionnaires revealed that the women in the experimental group observed an improvement in their body image perception and self-esteem and a decrease in their levels of anxiety and depression. There was no significant change between the pre- and post-operative scores of the experimental group in the sexual satisfaction index. Between the experimental group and the control group, a statistically significant difference was seen only for preoperative anxiety levels. Conclusion: Reduction mammoplasty had a favorable effect on the self-esteem, body image perception, depression, and anxiety but had no impact on sexual satisfaction of the patients. Level of evidence: Level II, Evidence obtained from well-designed controlled trials without randomization.
Keywords: Depression, macromastia, reduction mammoplasty, self-esteem
|How to cite this article:|
Oral MA, Aslan C, Tuzuner M, Aksam E, Kilin Capkinoglu FB, Gulpek D. The effects of breast reduction on sexual activity. Turk J Plast Surg 2018;26:62-6
| Introduction|| |
Female sexual dysfunction is more complicated than male sexual dysfunction and has both physiological and psychological causes. Physiological conditions of dysfunction are examined under subgroups as hormonal, vascular, muscular, and neurogenic causes. The main psychological factors affecting sexual function in female include self-esteem, body perception, mood disorders, partner compatibility, fatigue, and stress. Macromastia may produce adverse effects on sexual life in many aspects as a result of its physiological and psychological effects on patients. Physical effects of macromastia may include the neck, back and shoulder pains, and skin disorders such as dermatitis, while adverse psychological effects may include a negative perception of body image, low self-esteem, and predisposition to depression and anxiety, all of which may be reflected in the social and sexual life of the patient.,
Conservative approaches that involve weight loss programs, the use of reinforced underclothing and physical therapy to overcome the discomfort caused by macromastia cannot be considered permanent solutions for most patients. Thus, breast reduction surgery appears to be the most effective treatment for the restoration of their physical and psychosocial well-being. There are many studies that highlight the positive psychosocial effects of breast reduction surgery, and while several of these studies have addressed self-esteem, anxiety, and quality of life, the impact on the patients' sex life and marital adjustment has not been sufficiently investigated.,,
The intention of this study is to evaluate the psychological effects of breast reduction surgery using self-esteem, body image, anxiety and depression, and scales and to investigate the impact of breast reduction surgery on sexual satisfaction and marital adjustment.
| Materials and Methods|| |
This study was conducted in the Department of Plastic Surgery of the Izmir Katip Celebi University, Ataturk Training and Research Hospital between 2012 and 2013, according to the guidelines of the Declaration of Helsinki and the study protocol approved by the Ethics Committee of the Izmir Katip Celebi University. The study was designed as a prospective, controlled survey that included patients with macromastia as the experimental group and healthy women as the control group.
Experimental group consisted of female patients between the ages of 25 and 55 years with the following characteristics: have sex regularly, a total breast volume above 1000 cc according to the Grossman-Roudner device, a distance between sternal notch and nipple that measured 27 cm or more and a report of physical complaints (i.e., neck pain, back pain, shoulder pain, and intertrigo) related to macromastia. Patients with chronic physical or psychiatric illnesses, a history of breastfeeding in the last year, or significant breast asymmetry (a difference of 2 cm or more in the level between the nipples) excluded from the study.
Control group consisted of healthy females who have sex regularly, a total breast volume above 1000 cc according to the Grossman-Roudner device, a distance between sternal notch and nipple that measured 27 cm or more and a report of physical complaints (i.e., neck pain, back pain, shoulder pain, and intertrigo) related to macromastia and who did not accept reduction mammoplasty surgery for some reason. Females with chronic physical or psychiatric illnesses, and a history of breastfeeding in the last year, or significant breast asymmetry also excluded from the control group similar to the experimental group.
Rosenberg self-esteem scale, body-cathexis scale, Beck anxiety inventory, Beck depression inventory (BDI), Golombok rust inventory of sexual satisfaction (GRISS), and the dyadic adjustment scale were administered to the patients in the experimental group (n = 25), 1 month before and 12 months after the surgery. Same questionnaires were administered to the patients in the control group (n = 23) only once. An inferior pedicle breast reduction technique with an inverted “T” scar was used in all of the patients in the experimental group.
Questionnaire 1: Rosenberg self-esteem scale
The Rosenberg self-esteem scale was developed by Morris Rosenberg in 1965 and was validated for use in Turkey by Cuhadaroglu et al. It is a 10-item scale that measures an individual's global self-worth. All items are answered using a four-point Likert scale format ranging from 1 (strongly disagree) to 4 (strongly agree). A high score on the scale indicates impairment to self-esteem.,
Questionnaire 2: Body cathexis scale
The body cathexis scale was developed by Secord and Jourard in 1953 and aims to assess an individual's level of satisfaction with his or her physical appearance. The scale contains 40 items and each item is related to a part (arms, legs, and face) or a function (such as the level of sexual activity) of the body. Each item was answered using a five-point Likert scale format ranging from 1 (have strong feelings and wish change could somehow be made), 2 (do not like but can put up with), 3 (have no particular feelings one way or the other), 4 (am satisfied), and 5 (consider myself fortunate). A high score indicates a higher dissatisfaction with one's physical appearance. The scale was validated by Hovardaoglu et al., for use in Turkey and has been reported as a reliable tool.,
Questionnaire 3: Beck depression inventory
The BDI was developed by Beck et al., in 1961 and is applicable to adults and adolescents above the age of 15. The scale contains 21 multiple choice items and each item is scored from 0 to 3. The total score of the scale ranges 0–63. The range of 0–9 points means normal, mild depressive symptoms with 10–16 points, moderate depressive symptoms with 17–29 points, and depressive symptoms with 30–63 points. This inventory may be used to determine the risk of depression and its severity level. This scale was validated by Hisli et al., for use in Turkey in 1989.,
Questionnaire 4: Beck anxiety inventory
This inventory was developed by Beck et al., in 1988, and seeks to measure the frequency of symptoms of anxiety in an individual. The inventory contains 21 items and is a Likert-type self-rated scale ranging from 0 to 3. A high total score indicates an elevated level of anxiety. The range of 0–7 points means normal, mild anxiety with 8–15 points, moderate anxiety with 16–25 points and as severe anxiety with 26–63 points. The scale was validated by Ulusoy and Erkman for use in Turkey.,
Questionnaire 5: Golombok rust inventory of sexual satisfaction
This inventory was developed by Golombok and Rust in 1986 and is used for the evaluation of the quality of sexual intercourse and for evaluating sexual dysfunction. The inventory contains two separate forms, one for men and one for women, each of which contains 28 questions that are answered on a five-point (Likert type) scale. GRISS provides the overall scores and subscale scores. The quality of sexual functioning within a relationship can be obtained from the overall scores. In addition, subscale scores are particularly helpful for the assessment of infrequency, noncommunication, dissatisfaction, avoidance, nonsensuality, anorgasmia, and vaginismus. All scores were converted to a scale ,,,,,,,, and a low score indicates impairments in sexual function and sexual intercourse. Although there are many scales used in clinical studies on sexual satisfaction, this questionnaire was selected because GRISS evaluates both mental and physical factors includes multiplechoice, free-response items, so it is easy to answer and does not include a specific reference period (e.g., past 4 weeks). The GRISS was validated for its use in Turkey by Tuǧrul and Kabakçı in 1993.
Questionnaire 6: Dyadic adjustment scale
This scale was developed by Graham and Spanier in 1976 and encompasses attitudes, behaviors, and cognitive processes. This scale can be used to assess sexual satisfaction and to evaluate the level of marital adjustment; 32-item scale contains four subscales:
- Dyadic satisfaction (trusting each other, general pleasure in relationship, 10 items)
- Dyadic cohesion (having exchange of ideas, having interests in common, 5 items)
- Dyadic consensus (agreement on key issues, etc. financial matters, general view of life; 13 items)
- Affectional expression (expressions of love, 4 items).
The high scores indicating a greater compliance between the couples. A validity study for Turkish population has been conducted by Fişiloǧlu and Demir in 2000.
The SPSS 15.0 for Windows software package was used in the statistical analysis of the data using 95% confidence intervals (IBM SPSS Inc. Chicago, USA). A Pearson's Chi-square test was used to compare the categorical variables between the groups, a Mann–Whitney U-test was used to compare the continuous variables between the groups, and a Wilcoxon signed-ranks test was used to compare the pre- and postoperative values. P < 0.05 was considered statistically significant. The qualification of the sample size was determined by power analysis.
| Results|| |
Demographic features of the participants in the experimental and control groups are presented in [Table 1] and [Table 2]; the physical complaints of the patients in the experimental group are presented in [Table 3]. As the data reveal, there was no difference between the experimental and control groups in terms of their sociodemographic backgrounds and comorbidities. In this study, back pain was the most commonly reported complaint in patients with macromastia. Average breast reduction volume was 673.2 ± 178 g for each breast (between 410–1020 g). All patients were followed for at least 1 year. Wound dehiscence in T junction point was seen in three patients, but all healed without any surgical intervention.
|Table 1: Distribution of the occupational status and educational level of the cases|
Click here to view
|Table 2: Comparative analysis of the two groups in terms of age and body mass index|
Click here to view
Patients in the experimental group achieved significantly lower postoperative scores in self-esteem and body-cathexis scale as well as in the Beck anxiety and BDIs than they did in the preoperative analysis (P< 0.05). They also achieved significantly higher postoperative scores on the dyadic adjustment scale compared with their preoperative scores (P< 0.05). The difference between the pre- and postoperative scores on the GRISS was not statistically significant (P > 0.05). The average distribution of the survey results of the experimental group is shown in [Table 4].
|Table 4: Average distribution of the pre- and postoperative scores in the experimental group|
Click here to view
Compared with the control group, the patients in the experimental group achieved significantly higher preoperative scores in the Beck anxiety inventory (P< 0.05). There were no statistically significant differences between the groups in the other variables (P > 0.05). The average distribution of the survey results of the two groups is shown in [Table 5].
|Table 5: Statistical comparison of the scores between the control and experimental groups|
Click here to view
| Discussion|| |
The assessment of postoperative outcomes in plastic surgery utilizes multiple parameters including those related to esthetics, complaints, and psychosocial aspects. In the present study, the outcomes of breast reduction surgery were assessed from a psychosocial perspective.
In the assessment of the Rosenberg self-esteem scale and body-cathexis scale scores, the patients in the experimental group achieved significantly lower postoperative scores, which reflect an improvement in self-esteem and body image perception. Likewise, the patients in the experimental group achieved significantly lower postoperative scores in the Beck anxiety and BDIs, which indicate decreased the levels of anxiety and depression in the postoperative period. The previous studies have reported similar findings Saariniemi et al. tested the effects of breast reduction on self-esteem, depression, and anxiety using Raitasalo's modification of the short form of the BDI in a prospective and randomized study and reported that the breast reduction surgery improved the self-esteem of the patients and also had positive effects on depression and anxiety. In another study, Sabino Neto et al. tested the effects of breast reduction surgery on self-esteem and functional capacity of the patients using Rosenberg self-esteem scale and Roland–questionnaires Morris (to assess functional capacity) and reported that breast reduction had positive effects on self-esteem and functional capacity. Glatt et al. reported positive effects of breast reduction on physical complaints and body perception of the patients in a retrospective study.
Anxiety levels in patients undergoing surgery for macromastia were found to be significantly higher than the anxiety levels in the patients in the control group and showed a regression after surgery to a similar level. Aside from this, no significant differences were identified between the experimental and control groups in terms of their pre- and postoperative scores in self-esteem, body image, depression level, sexual satisfaction, and marital adjustment.
The present study also evaluated the effects of breast reduction on the patients' sexual lives. As there is no widely accepted or validated questionnaire for the assessment of female sexual function, the impact of breast reduction surgery on the patients' sex lives was investigated using the GRISS, from which no significant difference could be detected between the pre- and postoperative scores. There are two earlier studies related to this topic, both of which were retrospective in nature. Cerovac et al. assessed 90 patients using a female sexual function index questionnaire and reported improved postoperative satisfaction in 28% of the patients, decreased satisfaction in 19% of the patients, and no change in 53% of the patients, while Romeo et al. conducted a controlled study using a female sexual function index questionnaire and reported no significant difference between the experimental and control groups. Both studies stressed the need for a prospective study to be conducted on this topic, and this study intends to fulfill this need. However, contrary to expectations, our study found no favorable effect of breast reduction surgery on sexual satisfaction.
Another important issue in the present study is the assessment of the impact of breast reduction surgery on marital adjustment. A review of the literature found no studies evaluating the effects of breast reduction on marital adjustment. In the present study, the patients in experimental group achieved significantly higher postoperative scores on the dyadic adjustment scale, which reflects an improvement in marital adjustment.
Similar to previous analyses, the present study identified favorable effects of breast reduction on the psychological status of the patients. The present study also assessed the effects of breast reduction on sexual activity and marital adjustment and found that while surgery improved marital adjustment, it did not produce a significant improvement in sexual activity.
| Conclusion|| |
It was assumed that the restoration of an anatomical feature that is central to one's sexual identity to a more acceptable form, in terms of physical health and visual appearance, would have a positive effect on the sex life of any given patient. The results of this prospective study showed that breast reduction has positive effects on self-esteem and body image perception and also it reduces depression and anxiety levels. However, no favorable effect was found about sexual life of patients. We believe that the possible reason for this is the complex structure of female sexual behavior that is interconnected common effects of physiological, anatomical, and psychological factors. More studies like this are needed to define these complex factors.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Frank JE, Mistretta P, Will J. Diagnosis and treatment of female sexual dysfunction. Am Fam Physician 2008;77:635-42.
Latif EZ, Diamond MP. Arriving at the diagnosis of female sexual dysfunction. Fertil Steril 2013;100:898-904.
Hermans BJ, Boeckx WD, De Lorenzi F, van der Hulst RR. Quality of life after breast reduction. Ann Plast Surg 2005;55:227-31.
Netscher DT, Meade RA, Goodman CM, Brehm BJ, Friedman JD, Thornby J, et al.
Physical and psychosocial symptoms among 88 volunteer subjects compared with patients seeking plastic surgery procedures to the breast. Plast Reconstr Surg 2000;105:2366-73.
Collins ED, Kerrigan CL, Kim M, Lowery JC, Striplin DT, Cunningham B, et al.
The effectiveness of surgical and nonsurgical interventions in relieving the symptoms of macromastia. Plast Reconstr Surg 2002;109:1556-66.
Blomqvist L, Brandberg Y. Three-year follow-up on clinical symptoms and health-related quality of life after reduction mammaplasty. Plast Reconstr Surg 2004;114:49-54.
Cerovac S, Ali FS, Blizard R, Lloyd G, Butler PE. Psychosexual function in women who have undergone reduction mammaplasty. Plast Reconstr Surg 2005;116:1306-13.
Singh KA, Losken A. Additional benefits of reduction mammaplasty: A systematic review of the literature. Plast Reconstr Surg 2012;129:562-70.
Cuhadaroglu F. Self-esteem in adolescents Specialization Thesis. Ankara: Hacettepe University School of Medicine; 1986.
Rosenberg M. Society and the Adolescent Self-Image. New Jersey, USA: Princeton University Press Princeton, NJ; 1965.
Hovardaoglu S. The Study of Reliability and Validity of Body Cathezxis Scale Bachelor's Degree Thesis. Ankara: Gazi University Institute of Social Science; 1990.
Secord PF, Jourard SM. The appraisal of body-cathexis: Body-cathexis and the self. J Consult Psychol 1953;17:343-7.
Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. Arch Gen Psychiatry 1961;4:561-71.
Hisli N. The validity and reliability of the beck depression inventory for university students. Turk J Psychol 1989;7:3-13.
Beck AT, Epstein N, Brown G, Steer RA. An inventory for measuring clinical anxiety: Psychometric properties. J Consult Clin Psychol 1988;56:893-7.
Ulusoy MS, Erkman H. Turkish version of the beck anxiety inventory: psychometric properties. J Cogn Psychother 1998;12:28-35.
Rust J, Golombok S. The GRISS: A psychometric instrument for the assessment of sexual dysfunction. Arch Sex Behav 1986;15:157-65.
Tuǧrul CÖ, Kabakçı E. Standardization of golombok-rust sexual satisfaction inventory. Turk J Psychiatry 1993;4:83-8.
GB S. Measuring dyadic adjustment: New scale for assessing the quality of marriage and similar dyads. J Marriage Fam 1976;38:15-28.
Fişiloǧlu H, Demir A. applicability of the dyadic adjustment scale for measurement of marital quality with Turkish couples. Eur J Psychol Assess 2000;16:214.
Saariniemi KM, Joukamaa M, Raitasalo R, Kuokkanen HO. Breast reduction alleviates depression and anxiety and restores self-esteem: A prospective randomised clinical trial. Scand J Plast Reconstr Surg Hand Surg 2009;43:320-4.
Sabino Neto M, Demattê MF, Freire M, Garcia EB, Quaresma M, Ferreira LM, et al.
Self-esteem and functional capacity outcomes following reduction mammaplasty. Aesthet Surg J 2008;28:417-20.
Glatt BS, Sarwer DB, O'Hara DE, Hamori C, Bucky LP, LaRossa D, et al.
Aretrospective study of changes in physical symptoms and body image after reduction mammaplasty. Plast Reconstr Surg 1999;103:76-82.
Romeo M, Cuccia G, Zirilli A, Weiler-Mithoff E, Stagno d'Alcontres F. Reduction mammaplasty and related impact on psychosexual function. J Plast Reconstr Aesthet Surg 2010;63:2112-6.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]