BREAST SURGERY
Sexual Function and Depression Outcomes Among Breast Hypertrophy Patients Undergoing Reduction Mammaplasty A Randomized Controlled Trial Flávia N. M. Beraldo, PhD,* Daniela F. Veiga, MD, PhD,*† Joel Veiga-Filho, MD, PhD,† Edgard S. Garcia, MD, PhD,*† Gerusa S. Vilas-Bôas, MD,‡ Yara Juliano, PhD,§ Miguel Sabino-Neto, MD, PhD,* and Lydia M. Ferreira, MD, PhD* Purpose: The breasts are important symbols of femininity and sensuality. Alterations such as breast hypertrophy can affect several aspects of women's quality of life. Breast hypertrophy is a prevalent health condition, which is treated by reduction mammaplasty. The aim of the present study was to assess sexual function and depression outcomes among breast hypertrophy patients undergoing reduction mammaplasty. Methods: Sixty breast hypertrophy patients were randomly allocated to a control group (CG) (n = 30) or a breast reduction group (BRG) (n = 30). The patients in the CG were assessed at the first appointment as well as 3 and 6 months later. The patients in the BRG were assessed preoperatively as well as 3 and 6 months postoperatively. Validated instruments, the Female Sexual Function Index and the Beck Depression Inventory, were used to assess sexual function and depression among the subjects. The results of these assessments were compared within and between groups. Results: Twenty-seven and 29 patients in the CG and the BRG, respectively, completed the 6-month follow-up period. At baseline, the groups did not differ significantly with regard to the main demographic data. In the initial assessment, the groups did not differ significantly with regard to Female Sexual Function Index or Beck Depression Inventory scores. Compared with the CG, the BRG reported better sexual function 3 (P = 0.015) and 6 (P = 0.009) months postoperatively. Regarding depression scores, the reduction mammaplasty group had better results 6 months postoperatively (P = 0.014). Conclusions: Reduction mammaplasty positively affected sexual function and depression levels in breast hypertrophy patients. Key Words: breast, mammaplasty, sexuality, depression, quality of life (Ann Plast Surg 2016;76: 379–382)
T
he breasts play a major role in women's health, especially regarding breastfeeding, femininity, and sexual symbolism. Discrepancies between actual and idealized breasts can create psychological problems that interfere with social life. Thus, changes in the breasts, such as hypertrophy, may be treated as anomalies that can severely affect women's quality of life.1,2 Breast hypertrophy is a prevalent health condition, which is treated by reduction mammaplasty. Several previous studies demonstrate that reduction mammaplasty reduces symptoms associated with breast hypertrophy, positively affecting different aspects of the quality of life
Received August 12, 2014, and accepted for publication, after revision, October 6, 2014. From the *Translational Surgery Graduate Program, Universidade Federal de São Paulo, São Paulo; and †Division of Plastic Surgery, Department of Surgery, ‡School of Medicine, and §Department of Biostatistics, Universidade do Vale do Sapucaí, Pouso Alegre, Brazil. Conflicts of interest and sources of funding: none declared. Reprints: Daniela F. Veiga, MD, PhD, Rua Napoleão de Barros, 715, 4 andar, Vila Clementino, São Paulo, SP CEP 04024-002, Brazil. E-mail: [email protected]. Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/16/7604–0379 DOI: 10.1097/SAP.0000000000000380
Annals of Plastic Surgery • Volume 76, Number 4, April 2016
of patients, such as self-esteem, depression, body image, and functional capacity.2–10 Sexual health is increasingly being recognized as an important aspect of quality of life.11 However, a literature search revealed only 2 retrospective studies that evaluated sexual function in women undergoing reduction mammaplasty.12,13 Depression is approximately twice more prevalent in women than men.14 Previous studies assessing depression in patients undergoing reduction mammaplasty used different questionnaires for evaluation; however, all demonstrate the positive impact of reduction mammaplasty on the symptoms of depression.8,10,12,13,15,16 At present, to the best of our knowledge, there are no prospective randomized studies in the literature using the Female Sexual Function Index (FSFI) and the Beck Depression Inventory (BDI) to evaluate patients undergoing reduction mammaplasty. Therefore, this study evaluated sexual function and depression levels in patients with breast hypertrophy undergoing reduction mammaplasty.
METHODS This randomized controlled trial was performed in the Plastic Surgery Clinic of a university-affiliated hospital (Hospital das Clínicas Samuel Libânio, Universidade do Vale do Sapucaí). The study protocol was approved by the institutional Ethics Committee and registered in the ClinicalTrials.gov Protocol Registration System (NCT01020422). Other authors found a proportion of 53% of patients with adequate sexual function after reduction mammaplasty.12 We considered a 30% difference clinically relevant. Specifying an acceptable type I error of 5% and type II error of 20%, the estimated sample size was 30 subjects per arm. Thus, 60 breast hypertrophy patients were prospectively enrolled. Breast hypertrophy was defined by means of criteria of Sacchini et al.17 The exclusion criteria were as follows: younger than 18 years or older than 60 years; body mass index (BMI) of 30 kg/m2 or higher; prior breast surgery (reconstructive or esthetic); uncontrolled systemic diseases; patients undergoing investigation for breast pathologies; acute diseases; breast asymmetry; history of psychiatric treatment; and pregnancy, childbirth, or breastfeeding within 1 year. Patients were randomly allocated to 2 groups: control group (CG, n = 30) or breast reduction group (BRG, n = 30). The randomization sequence was computer generated, and allocation concealment was ensured by a sealed numbered opaque envelope opened at the end of the initial consultation, after the signature of the informed consent form. The patients in the CG were followed for 6 months and evaluated at 3 time points (baseline as well as after 3 and 6 months). The patients allocated in the BRG underwent reduction mammaplasty, performed by the same surgical team, under general anesthesia. A traditional inverted T-scar medial pedicle technique was used. These patients were assessed preoperatively as well as 3 and 6 months after reduction mammaplasty. To assess sexual function, the Brazilian version of the FSFI was used.11,18,19 The index has 19 questions about the sexual activity of www.annalsplasticsurgery.com
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TABLE 1. Initial FSFI and BDI Scores
TABLE 3. FSFI and BDI Scores After 6 Months
Domain
CG, Mean (SD) [Median]
BRG, Mean (SD) [Median]
CG vs BRG, Mann-Whitney U Test
Desire Excitement Lubrication Orgasm Satisfaction Pain FSFI total score BDI
3.6 (1.1) [3.6] 3.4 (1.8) [3.6] 4.1 (2.0) [4.5] 3.9 (2.0) [4.8] 4.4 (1.6) [4.8] 4.3 (2.0) [4.8] 23.9 (9.6) [27.6] 13.2 (9.6) [13.0]
3.9 (1.1) [3.6] 3.8 (1.7) [4.2] 4.3 (1.9) [5.1] 4.1 (1.9) [4.8] 4.2 (1.9) [4.8] 4.2 (2.0) [4.8] 24.7 (8.8) [27.3] 12.4 (9.0) [10.0]
P = 0.23 P = 0.27 P = 0.68 P = 0.89 P = 0.79 P = 0.63 P = 0.96 P = 0.89
patients during the last 4 weeks. Responses are grouped into 6 areas to obtain scores: desire, arousal, lubrication, orgasm, satisfaction, and discomfort/pain. The final scores can range from 2 to 36; higher scores indicate better sexual function. The cutoff of sexual dysfunction was 26.55; that is, a total score lower than this indicated sexual dysfunction.18–20 To assess depression, we used the BDI.21 The scale has 21 items including symptoms and attitudes whose intensity ranges from 0 to 3. The final score is obtained by summing the 21 items constituting the scale and read according to Beck and Steer22 as follows: less than 10, no or minimal depression; 10 to 16, mild depression; 17 to 29, moderate depression; and 30 to 63, severe depression.
Statistical Analysis The Mann-Whitney U test was used to compare both groups with regard to the total score and domain scores of the BDI at each of the 3 time points as well as age, BMI, and Sacchini et al index. The Friedman test was used to compare intragroup data along time. This test was applied separately for each FSFI domain and the total score. For the BDI, the Friedman test compared the values of the entire scale. The χ2 test was applied to compare the frequencies of the depression levels of the BDI and sexual dysfunction with regard to the FSFI cutoff score between groups and time points. The same test was applied to compare the groups regarding the education level. The Fisher test was used to assess the associations between weight of breast resection (up to median values and greater than median values) and the occurrence of sexual dysfunction or moderate/severe depression on postoperative months 3 and 6.
Domain
CG, Mean (SD) [Median]
BRG, Mean (SD) [Median]
CG vs BRG Mann-Whitney U Test
Desire Excitement Lubrication Orgasm Satisfaction Pain FSFI total score BDI
3.5 (1.2) [3.6] 3.3 (1.7) [3.6] 4.0 (1.9) [4.8] 3.5 (1.9) [4.4] 3.8 (2.0) [4.8] 4.3 (1.9) [4.8] 22.5 (9.3) [25.3] 13.7 (10.5) [13.0]
4.2 (1.0) [4.2] 4.3 (1.4) [4.5] 4.6 (1.7) [5.4] 4.5 (1.6) [5.2] 4.9 (1.6) [5.2] 4.8 (1.5) [5.6] 27.5 (6.9) [29.6] 7.2 (9.9) [3.0]
P = 0.02 P < 0.001 P = 0.05 P = 0.01 P = 0.01 P = 0.31 P < 0.001 P = 0.01
The level of significance was established at Ρ ≤ 0.05. The Statistical Package for the Social Sciences version 18.0 (SPSS, 2010 Inc, IBM Corp) was used for the analysis.
RESULTS Four patients withdrew from the study before the 6-month assessment. Three patients in the CG underwent reduction mammaplasty in another hospital and 1 patient in the BRG moved to another city and did not return for follow-up. Thus, 27 and 29 patients in the CG and the BRG, respectively, completed the 6-month follow-up period. The median age of the patients was 35 years in the CG (mean, 34.8 years) and 30 years in the BRG (mean, 30.3 years), P = 0.838. The median BMI in the CG and the BRG was 27.2 kg/m2 (mean, 27 kg/m2) and 24.9 kg/m2 (mean, 25.1 kg/m2), respectively (P = 0.004). There was no difference between groups regarding the classification of the right (P = 0.092) or the left breast (P = 0.224), according to the classification of Sacchini et al.17 There was also no difference between groups with regard to education level (P = 0.800). In the BRG, resection weight ranged from 650 to 2420 g (median, 1000 g; mean [SD], 1199.5 [455.7] g). Tables 1 to 3 show the scores of the FSFI and the BDI for both groups. In the initial interview, there were no differences between the groups (Table 1). Three months postoperatively, the BRG showed significantly better results for the FSFI domains desire (P = 0.02), excitement (P = 0.03), and lubrication (P = 0.02) and also for the FSFI
TABLE 4. Intragroup Assessments of FSFI and BDI Scores Initial 3 mo 6 mo
TABLE 2. FSFI and BDI Scores After 3 Months
Domain
Domain
CG, Mean (SD) [Median]
BRG, Mean (SD) [Median]
CG vs BRG, Mann-Whitney U Test
Desire Excitement Lubrication Orgasm Satisfaction Pain FSFI total score BDI
3.2 (0.8) [3.6] 3.1 (1.8) [3.6] 3.6 (2.1) [4.0] 3.3 (2.1) [4.0] 3.7 (2.1) [4.4] 3.6 (2.3) [4.4] 20.9 (9.8) [23.6] 13.0 (8.5) [12.0]
3.9 (1.1) [3.6] 4.0 (1.6) [4.5] 4.5 (1.9) [5.1] 4.1 (2.0) [4.8] 4.6 (1.8) [5.2] 4.4 (2.0) [5.2] 25.9 (9.3) [28.9] 10.2 (9.9) [6.0]
P = 0.02 P = 0.03 P = 0.02 P = 0.06 P = 0.07 P = 0.13 P = 0.01 P = 0.12
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CG
Desire Excitement Lubrication Orgasm Satisfaction Pain FSFI total score BDI
P = 0.06 P = 0.92 P = 0.11 P = 0.23 P = 0.11 P = 0.22 P < 0.001 Initial > 3 mo and 6 mo P = 0.89
BRG
P = 0.28 P = 0.09 P = 0.86 P = 0.43 P = 0.06 P = 0.50 P = 0.48 P < 0.001 Initial > 3 m and 6 m
Friedman test.
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Annals of Plastic Surgery • Volume 76, Number 4, April 2016
Sexual Function and Depression After Mammaplasty
TABLE 5. Frequencies of Sexual Dysfunction (FSFI Total Score ≤ 26.55) CG, n (%) With Dysfunction
Initial 3 mo 6 mo Intragroup comparison (with without dysfunction)
13 (48) 20 (74) 17 (63)
BRG, n (%)
Without Dysfunction
14 (52) 7 (26) 10 (37) 3.86, P = 0.14
With Dysfunction
10 (35) 12 (41) 7 (24)
Without Dysfunction
19 (65) 17 (59) 22 (76) 1.96, P = 0.37
Intergroup Comparison (With Without Dysfunction)
P = 0.29 P = 0.01 P < 0.001
χ2 test.
total score (P = 0.01) (Table 2). Six months postoperatively, the BRG maintained significantly higher scores for the domains desire (P = 0.02), excitement (P < 0.001), and lubrication (P = 0.05) as well as the FSFI total score (P < 0.001). Moreover, there was also significant improvement in the domains orgasm (P = 0.01) and satisfaction (P = 0.01) as well as the total BDI score (P = 0.01) (Table 3). In the intragroup assessment, the patients in the CG presented higher FSFI total scores at the initial assessment, when compared with both 3-month and 6-month assessments (P < 0.001), indicating worse sexual function at the initial assessment. The patients in the BRG had higher BDI scores preoperatively (P < 0.001), indicating higher depression levels preoperatively, when compared with both 3 and 6 months postoperatively (Table 4). The patients who underwent reduction mammaplasty also showed a lower frequency of sexual dysfunction (FSFI total score ≤ 26.55) postoperatively at both 3 (P = 0.013) and 6 months (P = 0.003) (Table 5). Table 6 shows the levels of depression at the 6-month interview for both groups. There were no associations between breast weight resection and the occurrence of sexual dysfunction on postoperative months 3 and 6 (P = 0.236 and P = 0.665, respectively). There were also no associations between weight resection and the occurrence of moderate or severe depression on postoperative months 3 (P = 0.665) and 6 (P = 0.998).
DISCUSSION Besides pain, patients seeking breast reduction also mention body dissatisfaction, which interferes with their self-esteem and therefore quality of life. Studies show that breast reduction positively affects aspects related to quality of life in women with breast hypertrophy.3–9 The importance of sexual health in quality of life has been increasingly recognized in recent years. Disturbances in any stage of sexual response can result in the manifestation of sexual dysfunction, damaging relationships and causing problems in other aspects of life, which in turn lead to anxiety and depression.23
TABLE 6. Frequencies of Depression Levels at 6 Months Level
Minimum depression Mild depression Moderate depression Severe depression Total
CG, n (%)
BRG, n (%)
9 (33) 8 (30) 8 (30) 2 (7) 27 (100)
22 (76) 2 (7) 4 (14) 1 (3) 29 (100)
χ2 test: P = 0.01.
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However, a literature search failed to find any prospective study assessing sexual function among women who underwent breast reduction. Only 2 retrospective studies evaluated sexual function after reduction mammaplasty, and none of them achieved statistical significance.12,13 The mean age of the patients in the present study (34.9 and 30.3 years in the CG and the BRG, respectively) reflects the main age group of patients seeking breast reduction mammaplasty.5 There was a significant difference between groups with respect to BMI (P = 0.004). This difference can be attributed to chance because the patients were randomly allocated to groups. The influence of BMI on breast hypertrophy remains controversial. We chose not to include obese patients (BMI > 30 kg/m2) because this could increase the postoperative complication rates and because obese women are more likely to present depression and decreased sexual function.24 However, Singh et al3 observed that breast reduction can be perceived as a motivation for future weight loss by breast hypertrophy patients. Most patients in both groups had more than 8 years of education, which facilitated the use of the self-administered form of the instruments in this study.11 Validated questionnaires assessing sexual function can assist research, enabling reliable comparison of results.25 The FSFI was the first instrument assessing female sexual function that has been translated into Portuguese, culturally adapted, and validated for use in the Brazilian population.11,18,19 In the initial interview, there were no significant differences between groups with respect to any FSFI domain, demonstrating its homogeneity. However, there was a significant difference in the domains desire, excitement, and lubrication as well as the total FSFI score 3 months after the surgical procedure. After 6 months, the BRG showed significant improvements in the domains orgasm and satisfaction, when compared with the CG. Therefore, the results of the present study do not confirm the findings of previous studies, which reported that breast size does not influence sexual function.12,13 The study of Pacagnella et al18 suggests a possible relationship between orgasm and satisfaction as well as orgasm and lubrication. In our study, in the BRG, the domains orgasm and satisfaction significantly improved only at 6 months. These results are comparable with those of the study of Furlanetto and Rodrigues,26 who report a strong relationship between orgasm and satisfaction in 80% of women. These finds suggest that Brazilian culture tends to project intercourse without orgasm as frustrating and considers orgasm a “victory.” In other words, if an orgasm occurs, there is sexual satisfaction.26 Thiel et al11 compared the domain satisfaction with the degree of emotional involvement between the woman and her partner, demonstrating that, if there is satisfactory emotional involvement, the score in this area is high. When considering the area “satisfaction,” which assesses the satisfaction with the emotional closeness of the couple, sexual satisfaction, and satisfaction with their sexual life in general, there were no significant differences between groups at the initial interview or after 3 months; a significant difference was apparent only after 6 months. www.annalsplasticsurgery.com
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In the area of “pain,” there was no significant difference between groups at any time point, corroborating the results of previous studies.19 In the current study, the last assessment of sexual function and depression outcomes was at 6 months postoperatively. Other authors also considered this period appropriate to detect differences in quality of life, self-esteem, functional capacity, and cosmetic outcomes after breast reduction.5–7,27 Our results demonstrate improvements in the sexual function of patients undergoing reduction mammaplasty at 3 and 6 months postoperatively, corroborating the results of a previous study.12 Some studies reported that, with an FSFI total score cutoff of 26.55 for the population of origin of the instrument, it is possible to discriminate between people with higher and lower risk for sexual dysfunction; values less than or equal to this point indicate sexual dysfunction.20,26 With the use of this cutoff value, there were fewer patients with sexual dysfunction in the group undergoing reduction mammaplasty at both 3 and 6 months postoperatively, confirming the positive impact of reduction mammaplasty on sexual function and quality of life in these patients. It should be noted that prospective studies evaluating depression in patients who underwent breast reduction are scarce.8,10,15,16 Studies on psychological changes after reduction mammaplasty have used various instruments to assess depression; the most commonly used is the Hospital Anxiety and Depression Scale.12,15,16 Only 1 study in the literature assessed depression in women with breast hypertrophy using the same instrument as that used in the present study and found that breast hypertrophy negatively affects the physical and psychological aspects of women.21 The well-standardized and widely used BDI has not been previously used in patients undergoing reduction mammaplasty. Two other studies used Raitasalo's modified version of the short form of the BDI.8,10 Therefore, we decided to use the BDI in the present study. Our results are similar to those of previous studies showing an association between breast hypertrophy and depressive symptoms and showing that women with breast hypertrophy have a higher rate of depressive symptoms than women who underwent reduction mammaplasty.8,10,15,16 Saariniemi et al8 reported that dissatisfaction with the outcome of surgery is related to anxiety and depression and that satisfaction with the operation is correlated with good preoperative information and a good relationship with the surgeon. Unfortunately, no instrument assessing patient satisfaction with the outcome of the surgery was used in the present study, making it impossible to confirm these associations. Souza Faria et al16 report that most patients are not clinically depressed before reduction mammaplasty and suggest that eventual mental disorders presented by women before surgery could be a direct result of their dissatisfaction with their breasts; such disturbances improved or were nonexistent after reduction mammaplasty. The present results corroborate these previous results. In general, reduction mammaplasty has been proven to effectively improve various aspects of the quality of life of patients, demonstrating that it provides not only esthetic benefits but also improvements in and relief from psychological symptoms due to mammary alteration.6,9
CONCLUSIONS In the current study, reduction mammaplasty improved patients' sexual function 3 and 6 months postoperatively and also improved depression levels at the sixth postoperative month. Thus, our results confirm the positive impact of reduction mammaplasty on the sexual function and depression levels of patients. This positive impact should be taken into account not only by the patients but also by managers
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and health care providers during the decision-making process regarding reduction mammaplasty. REFERENCES 1. Mello AA, Domingos NA, Miyazaki MC. Improvement in quality of life and selfesteem after breast reduction surgery. Aesthic Plast Surg. 2010;34:59–64. 2. Singh KA, Losken A. Additional benefits of reduction mammoplasty: a systematic review of the literature. Plast Reconstr Surg. 2012;129:562–570. 3. Singh KA, Pinell XA, Losken A. Is reduction mammaplasty a stimulus for weight loss and improved quality of life? Ann Plast Surg. 2010;64:585–587. 4. Kuzbari R, Schlenz I. Reduction mammaplasty and sensitivity of the nipple-areola complex: sensuality versus sexuality? Ann Plast Surg. 2007;58:3–11. 5. Freire MAMS, Sabino Neto M, Garcia EB, et al. Quality of life after reduction mammaplasty. Scand J Plast Reconstr Surg Hand Surg. 2004;38:335–339. 6. Freire M, Sabino Neto M, Garcia EB, et al. Functional capacity and postural pain outcomes after reduction mammaplasty. Plast Reconstr Surg. 2007;119:1149–1156. 7. Sabino Neto M, Demattê MF, Freire M, et al. Self-esteem and function capacity outcomes following reduction mammaplasty. Aesthet Surg J. 2008;4:417–420. 8. Saariniemi KM, Joukamaa M, Raitasalo R, et al. Breast reduction alleviates depression and anxiety and restores self-esteem: a prospective randomized clinical trial. Scand J Plast Reconstr Surg Hand Surg. 2009;43:320–324. 9. Saariniemi KM, Keranen UH, Salminen-Peltola PK, et al. Reduction mammaplasty is effective treatment according to two quality of life instruments: a prospective randomised clinical trial. J Plast Reconstr Aesthet Surg. 2008;61:1472–1478. 10. Saariniemi KM, Kuokkanen HO, Tukiainen EJ. The outcome of reduction mammaplasty remains stable at 2-5 years' follow-up: a prospective study. J Plast Reconstr Aesthet Surg. 2011;64:573–576. 11. Thiel RRC, Dambros M, Palmas PCR, et al. Translation in to Portuguese, crossnational adaptation and validation of the Female Sexual Function Index. Rev Bras Ginecol Obstet. 2008;30:504–510. 12. Cerovac S, Ali F, Blizard R, et al. Psychosexual function in womem who have undergone reduction mammaplasty. Plast Reconstr Surg. 2005;116:1306–1313. 13. Romeo M, Cuccia G, Zirilli A, et al. Reduction mammaplasty and related impact on psychosexual function. J Plast Reconstr Aesthet Surg. 2010;63:2112–2116. 14. Justo LP, Calil HM. Depression: the same affection for men and women? Rev Psiquiatr Clin. 2006;33:74–79. 15. Iwuagwu OC, Stanley PW, Platt AJ, et al. Effects of bilateral breast reduction on anxiety and depression: results of a prospective randomized trial. Scand J Plast Reconstr Surg Hand Surg. 2006;40:19–23. 16. Souza Faria F, Guthrie E, Bradbury E, et al. Psychosocial outcome and patient satisfaction following breast reduction surgery. Br J Plast Surg. 1999;52:448–452. 17. Sacchini V, Luini A, Tana S, et al. Quantitative and qualitative cosmetic evaluation after conservative treatment for breast cancer. Eur J Cancer. 1991;27:1395–1400. 18. Pacagnella RC, Vieira EM, Rodrigues OM Jr, et al. Cross-cultural adaptation of the Female Sexual Function Index. Cad Saude Publica. 2008;24:416–426. 19. Pacagnella RC, Martinez EZ, Vieira EM. Construct validity of a Portuguese version of the Female Sexual Female Index. Cad Saude Publica. 2009;25:2333–2344. 20. Wiegel M, Meston C, Rosen R. The Female Sexual Function Index (FSFI): crossvalidation and development of clinical cutoff scores. J Sex Marital Ther. 2005;31:1–20. 21. Gorestein C, Andrade L. Beck Depression Inventory: psychometric properties of the Portuguese version. Rev Bras Psiquiatr Clin. 1998;25:245–250. 22. Beck AT, Steer RA. Beck Depression Inventory: Manual. San Antonio, TX: Psychological Corp; 1993. 23. Valadares ALR, Pinto-Neto AM, Sousa MH, et al. Sociocultural adaptation of the Short Personal Experiences Questionnaire (SPEQ) in Brazil. Rev Bras Ginecol Obstet. 2010;32:72–76. 24. Saarwer DB, Lavery M, Spitzer JC. A review of the relationships between extreme obesity, quality of life, and sexual function. Obes Surg. 2012;22:668–676. 25. Pasqualotto EB, Pasqualotto FF, Sobreiro BP, et al. Female sexual dysfunction: the important points to remember. Clinics. 2005;60:51–60. 26. Furlanetto S, Rodrigues O Jr. Sexual satisfaction of the adult woman. Rev Bras Sex Hum. 1996;7:131–143. 27. Breiting LB, Henriksen TF, Kalialis LV, et al. A prospective study of short- and long-term cosmetic outcome after reduction mammaplasty from three different perspectives: the patient, a department surgeon, and an independent private practitioner in plastic surgery. Plast Reconstr Surg. 2012;130:273–281.
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Sexual Function and Depression Outcomes Among Breast Hypertrophy Patients Undergoing Reduction Mammaplasty A Randomized Controlled Trial Flávia N. M. Beraldo, PhD,* Daniela F. Veiga, MD, PhD,*† Joel Veiga-Filho, MD, PhD,† Edgard S. Garcia, MD, PhD,*† Gerusa S. Vilas-Bôas, MD,‡ Yara Juliano, PhD,§ Miguel Sabino-Neto, MD, PhD,* and Lydia M. Ferreira, MD, PhD* Purpose: The breasts are important symbols of femininity and sensuality. Alterations such as breast hypertrophy can affect several aspects of women's quality of life. Breast hypertrophy is a prevalent health condition, which is treated by reduction mammaplasty. The aim of the present study was to assess sexual function and depression outcomes among breast hypertrophy patients undergoing reduction mammaplasty. Methods: Sixty breast hypertrophy patients were randomly allocated to a control group (CG) (n = 30) or a breast reduction group (BRG) (n = 30). The patients in the CG were assessed at the first appointment as well as 3 and 6 months later. The patients in the BRG were assessed preoperatively as well as 3 and 6 months postoperatively. Validated instruments, the Female Sexual Function Index and the Beck Depression Inventory, were used to assess sexual function and depression among the subjects. The results of these assessments were compared within and between groups. Results: Twenty-seven and 29 patients in the CG and the BRG, respectively, completed the 6-month follow-up period. At baseline, the groups did not differ significantly with regard to the main demographic data. In the initial assessment, the groups did not differ significantly with regard to Female Sexual Function Index or Beck Depression Inventory scores. Compared with the CG, the BRG reported better sexual function 3 (P = 0.015) and 6 (P = 0.009) months postoperatively. Regarding depression scores, the reduction mammaplasty group had better results 6 months postoperatively (P = 0.014). Conclusions: Reduction mammaplasty positively affected sexual function and depression levels in breast hypertrophy patients. Key Words: breast, mammaplasty, sexuality, depression, quality of life (Ann Plast Surg 2016;76: 379–382)
T
he breasts play a major role in women's health, especially regarding breastfeeding, femininity, and sexual symbolism. Discrepancies between actual and idealized breasts can create psychological problems that interfere with social life. Thus, changes in the breasts, such as hypertrophy, may be treated as anomalies that can severely affect women's quality of life.1,2 Breast hypertrophy is a prevalent health condition, which is treated by reduction mammaplasty. Several previous studies demonstrate that reduction mammaplasty reduces symptoms associated with breast hypertrophy, positively affecting different aspects of the quality of life
Received August 12, 2014, and accepted for publication, after revision, October 6, 2014. From the *Translational Surgery Graduate Program, Universidade Federal de São Paulo, São Paulo; and †Division of Plastic Surgery, Department of Surgery, ‡School of Medicine, and §Department of Biostatistics, Universidade do Vale do Sapucaí, Pouso Alegre, Brazil. Conflicts of interest and sources of funding: none declared. Reprints: Daniela F. Veiga, MD, PhD, Rua Napoleão de Barros, 715, 4 andar, Vila Clementino, São Paulo, SP CEP 04024-002, Brazil. E-mail: [email protected]. Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/16/7604–0379 DOI: 10.1097/SAP.0000000000000380
Annals of Plastic Surgery • Volume 76, Number 4, April 2016
of patients, such as self-esteem, depression, body image, and functional capacity.2–10 Sexual health is increasingly being recognized as an important aspect of quality of life.11 However, a literature search revealed only 2 retrospective studies that evaluated sexual function in women undergoing reduction mammaplasty.12,13 Depression is approximately twice more prevalent in women than men.14 Previous studies assessing depression in patients undergoing reduction mammaplasty used different questionnaires for evaluation; however, all demonstrate the positive impact of reduction mammaplasty on the symptoms of depression.8,10,12,13,15,16 At present, to the best of our knowledge, there are no prospective randomized studies in the literature using the Female Sexual Function Index (FSFI) and the Beck Depression Inventory (BDI) to evaluate patients undergoing reduction mammaplasty. Therefore, this study evaluated sexual function and depression levels in patients with breast hypertrophy undergoing reduction mammaplasty.
METHODS This randomized controlled trial was performed in the Plastic Surgery Clinic of a university-affiliated hospital (Hospital das Clínicas Samuel Libânio, Universidade do Vale do Sapucaí). The study protocol was approved by the institutional Ethics Committee and registered in the ClinicalTrials.gov Protocol Registration System (NCT01020422). Other authors found a proportion of 53% of patients with adequate sexual function after reduction mammaplasty.12 We considered a 30% difference clinically relevant. Specifying an acceptable type I error of 5% and type II error of 20%, the estimated sample size was 30 subjects per arm. Thus, 60 breast hypertrophy patients were prospectively enrolled. Breast hypertrophy was defined by means of criteria of Sacchini et al.17 The exclusion criteria were as follows: younger than 18 years or older than 60 years; body mass index (BMI) of 30 kg/m2 or higher; prior breast surgery (reconstructive or esthetic); uncontrolled systemic diseases; patients undergoing investigation for breast pathologies; acute diseases; breast asymmetry; history of psychiatric treatment; and pregnancy, childbirth, or breastfeeding within 1 year. Patients were randomly allocated to 2 groups: control group (CG, n = 30) or breast reduction group (BRG, n = 30). The randomization sequence was computer generated, and allocation concealment was ensured by a sealed numbered opaque envelope opened at the end of the initial consultation, after the signature of the informed consent form. The patients in the CG were followed for 6 months and evaluated at 3 time points (baseline as well as after 3 and 6 months). The patients allocated in the BRG underwent reduction mammaplasty, performed by the same surgical team, under general anesthesia. A traditional inverted T-scar medial pedicle technique was used. These patients were assessed preoperatively as well as 3 and 6 months after reduction mammaplasty. To assess sexual function, the Brazilian version of the FSFI was used.11,18,19 The index has 19 questions about the sexual activity of www.annalsplasticsurgery.com
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TABLE 1. Initial FSFI and BDI Scores
TABLE 3. FSFI and BDI Scores After 6 Months
Domain
CG, Mean (SD) [Median]
BRG, Mean (SD) [Median]
CG vs BRG, Mann-Whitney U Test
Desire Excitement Lubrication Orgasm Satisfaction Pain FSFI total score BDI
3.6 (1.1) [3.6] 3.4 (1.8) [3.6] 4.1 (2.0) [4.5] 3.9 (2.0) [4.8] 4.4 (1.6) [4.8] 4.3 (2.0) [4.8] 23.9 (9.6) [27.6] 13.2 (9.6) [13.0]
3.9 (1.1) [3.6] 3.8 (1.7) [4.2] 4.3 (1.9) [5.1] 4.1 (1.9) [4.8] 4.2 (1.9) [4.8] 4.2 (2.0) [4.8] 24.7 (8.8) [27.3] 12.4 (9.0) [10.0]
P = 0.23 P = 0.27 P = 0.68 P = 0.89 P = 0.79 P = 0.63 P = 0.96 P = 0.89
patients during the last 4 weeks. Responses are grouped into 6 areas to obtain scores: desire, arousal, lubrication, orgasm, satisfaction, and discomfort/pain. The final scores can range from 2 to 36; higher scores indicate better sexual function. The cutoff of sexual dysfunction was 26.55; that is, a total score lower than this indicated sexual dysfunction.18–20 To assess depression, we used the BDI.21 The scale has 21 items including symptoms and attitudes whose intensity ranges from 0 to 3. The final score is obtained by summing the 21 items constituting the scale and read according to Beck and Steer22 as follows: less than 10, no or minimal depression; 10 to 16, mild depression; 17 to 29, moderate depression; and 30 to 63, severe depression.
Statistical Analysis The Mann-Whitney U test was used to compare both groups with regard to the total score and domain scores of the BDI at each of the 3 time points as well as age, BMI, and Sacchini et al index. The Friedman test was used to compare intragroup data along time. This test was applied separately for each FSFI domain and the total score. For the BDI, the Friedman test compared the values of the entire scale. The χ2 test was applied to compare the frequencies of the depression levels of the BDI and sexual dysfunction with regard to the FSFI cutoff score between groups and time points. The same test was applied to compare the groups regarding the education level. The Fisher test was used to assess the associations between weight of breast resection (up to median values and greater than median values) and the occurrence of sexual dysfunction or moderate/severe depression on postoperative months 3 and 6.
Domain
CG, Mean (SD) [Median]
BRG, Mean (SD) [Median]
CG vs BRG Mann-Whitney U Test
Desire Excitement Lubrication Orgasm Satisfaction Pain FSFI total score BDI
3.5 (1.2) [3.6] 3.3 (1.7) [3.6] 4.0 (1.9) [4.8] 3.5 (1.9) [4.4] 3.8 (2.0) [4.8] 4.3 (1.9) [4.8] 22.5 (9.3) [25.3] 13.7 (10.5) [13.0]
4.2 (1.0) [4.2] 4.3 (1.4) [4.5] 4.6 (1.7) [5.4] 4.5 (1.6) [5.2] 4.9 (1.6) [5.2] 4.8 (1.5) [5.6] 27.5 (6.9) [29.6] 7.2 (9.9) [3.0]
P = 0.02 P < 0.001 P = 0.05 P = 0.01 P = 0.01 P = 0.31 P < 0.001 P = 0.01
The level of significance was established at Ρ ≤ 0.05. The Statistical Package for the Social Sciences version 18.0 (SPSS, 2010 Inc, IBM Corp) was used for the analysis.
RESULTS Four patients withdrew from the study before the 6-month assessment. Three patients in the CG underwent reduction mammaplasty in another hospital and 1 patient in the BRG moved to another city and did not return for follow-up. Thus, 27 and 29 patients in the CG and the BRG, respectively, completed the 6-month follow-up period. The median age of the patients was 35 years in the CG (mean, 34.8 years) and 30 years in the BRG (mean, 30.3 years), P = 0.838. The median BMI in the CG and the BRG was 27.2 kg/m2 (mean, 27 kg/m2) and 24.9 kg/m2 (mean, 25.1 kg/m2), respectively (P = 0.004). There was no difference between groups regarding the classification of the right (P = 0.092) or the left breast (P = 0.224), according to the classification of Sacchini et al.17 There was also no difference between groups with regard to education level (P = 0.800). In the BRG, resection weight ranged from 650 to 2420 g (median, 1000 g; mean [SD], 1199.5 [455.7] g). Tables 1 to 3 show the scores of the FSFI and the BDI for both groups. In the initial interview, there were no differences between the groups (Table 1). Three months postoperatively, the BRG showed significantly better results for the FSFI domains desire (P = 0.02), excitement (P = 0.03), and lubrication (P = 0.02) and also for the FSFI
TABLE 4. Intragroup Assessments of FSFI and BDI Scores Initial 3 mo 6 mo
TABLE 2. FSFI and BDI Scores After 3 Months
Domain
Domain
CG, Mean (SD) [Median]
BRG, Mean (SD) [Median]
CG vs BRG, Mann-Whitney U Test
Desire Excitement Lubrication Orgasm Satisfaction Pain FSFI total score BDI
3.2 (0.8) [3.6] 3.1 (1.8) [3.6] 3.6 (2.1) [4.0] 3.3 (2.1) [4.0] 3.7 (2.1) [4.4] 3.6 (2.3) [4.4] 20.9 (9.8) [23.6] 13.0 (8.5) [12.0]
3.9 (1.1) [3.6] 4.0 (1.6) [4.5] 4.5 (1.9) [5.1] 4.1 (2.0) [4.8] 4.6 (1.8) [5.2] 4.4 (2.0) [5.2] 25.9 (9.3) [28.9] 10.2 (9.9) [6.0]
P = 0.02 P = 0.03 P = 0.02 P = 0.06 P = 0.07 P = 0.13 P = 0.01 P = 0.12
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CG
Desire Excitement Lubrication Orgasm Satisfaction Pain FSFI total score BDI
P = 0.06 P = 0.92 P = 0.11 P = 0.23 P = 0.11 P = 0.22 P < 0.001 Initial > 3 mo and 6 mo P = 0.89
BRG
P = 0.28 P = 0.09 P = 0.86 P = 0.43 P = 0.06 P = 0.50 P = 0.48 P < 0.001 Initial > 3 m and 6 m
Friedman test.
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Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Plastic Surgery • Volume 76, Number 4, April 2016
Sexual Function and Depression After Mammaplasty
TABLE 5. Frequencies of Sexual Dysfunction (FSFI Total Score ≤ 26.55) CG, n (%) With Dysfunction
Initial 3 mo 6 mo Intragroup comparison (with without dysfunction)
13 (48) 20 (74) 17 (63)
BRG, n (%)
Without Dysfunction
14 (52) 7 (26) 10 (37) 3.86, P = 0.14
With Dysfunction
10 (35) 12 (41) 7 (24)
Without Dysfunction
19 (65) 17 (59) 22 (76) 1.96, P = 0.37
Intergroup Comparison (With Without Dysfunction)
P = 0.29 P = 0.01 P < 0.001
χ2 test.
total score (P = 0.01) (Table 2). Six months postoperatively, the BRG maintained significantly higher scores for the domains desire (P = 0.02), excitement (P < 0.001), and lubrication (P = 0.05) as well as the FSFI total score (P < 0.001). Moreover, there was also significant improvement in the domains orgasm (P = 0.01) and satisfaction (P = 0.01) as well as the total BDI score (P = 0.01) (Table 3). In the intragroup assessment, the patients in the CG presented higher FSFI total scores at the initial assessment, when compared with both 3-month and 6-month assessments (P < 0.001), indicating worse sexual function at the initial assessment. The patients in the BRG had higher BDI scores preoperatively (P < 0.001), indicating higher depression levels preoperatively, when compared with both 3 and 6 months postoperatively (Table 4). The patients who underwent reduction mammaplasty also showed a lower frequency of sexual dysfunction (FSFI total score ≤ 26.55) postoperatively at both 3 (P = 0.013) and 6 months (P = 0.003) (Table 5). Table 6 shows the levels of depression at the 6-month interview for both groups. There were no associations between breast weight resection and the occurrence of sexual dysfunction on postoperative months 3 and 6 (P = 0.236 and P = 0.665, respectively). There were also no associations between weight resection and the occurrence of moderate or severe depression on postoperative months 3 (P = 0.665) and 6 (P = 0.998).
DISCUSSION Besides pain, patients seeking breast reduction also mention body dissatisfaction, which interferes with their self-esteem and therefore quality of life. Studies show that breast reduction positively affects aspects related to quality of life in women with breast hypertrophy.3–9 The importance of sexual health in quality of life has been increasingly recognized in recent years. Disturbances in any stage of sexual response can result in the manifestation of sexual dysfunction, damaging relationships and causing problems in other aspects of life, which in turn lead to anxiety and depression.23
TABLE 6. Frequencies of Depression Levels at 6 Months Level
Minimum depression Mild depression Moderate depression Severe depression Total
CG, n (%)
BRG, n (%)
9 (33) 8 (30) 8 (30) 2 (7) 27 (100)
22 (76) 2 (7) 4 (14) 1 (3) 29 (100)
χ2 test: P = 0.01.
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However, a literature search failed to find any prospective study assessing sexual function among women who underwent breast reduction. Only 2 retrospective studies evaluated sexual function after reduction mammaplasty, and none of them achieved statistical significance.12,13 The mean age of the patients in the present study (34.9 and 30.3 years in the CG and the BRG, respectively) reflects the main age group of patients seeking breast reduction mammaplasty.5 There was a significant difference between groups with respect to BMI (P = 0.004). This difference can be attributed to chance because the patients were randomly allocated to groups. The influence of BMI on breast hypertrophy remains controversial. We chose not to include obese patients (BMI > 30 kg/m2) because this could increase the postoperative complication rates and because obese women are more likely to present depression and decreased sexual function.24 However, Singh et al3 observed that breast reduction can be perceived as a motivation for future weight loss by breast hypertrophy patients. Most patients in both groups had more than 8 years of education, which facilitated the use of the self-administered form of the instruments in this study.11 Validated questionnaires assessing sexual function can assist research, enabling reliable comparison of results.25 The FSFI was the first instrument assessing female sexual function that has been translated into Portuguese, culturally adapted, and validated for use in the Brazilian population.11,18,19 In the initial interview, there were no significant differences between groups with respect to any FSFI domain, demonstrating its homogeneity. However, there was a significant difference in the domains desire, excitement, and lubrication as well as the total FSFI score 3 months after the surgical procedure. After 6 months, the BRG showed significant improvements in the domains orgasm and satisfaction, when compared with the CG. Therefore, the results of the present study do not confirm the findings of previous studies, which reported that breast size does not influence sexual function.12,13 The study of Pacagnella et al18 suggests a possible relationship between orgasm and satisfaction as well as orgasm and lubrication. In our study, in the BRG, the domains orgasm and satisfaction significantly improved only at 6 months. These results are comparable with those of the study of Furlanetto and Rodrigues,26 who report a strong relationship between orgasm and satisfaction in 80% of women. These finds suggest that Brazilian culture tends to project intercourse without orgasm as frustrating and considers orgasm a “victory.” In other words, if an orgasm occurs, there is sexual satisfaction.26 Thiel et al11 compared the domain satisfaction with the degree of emotional involvement between the woman and her partner, demonstrating that, if there is satisfactory emotional involvement, the score in this area is high. When considering the area “satisfaction,” which assesses the satisfaction with the emotional closeness of the couple, sexual satisfaction, and satisfaction with their sexual life in general, there were no significant differences between groups at the initial interview or after 3 months; a significant difference was apparent only after 6 months. www.annalsplasticsurgery.com
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In the area of “pain,” there was no significant difference between groups at any time point, corroborating the results of previous studies.19 In the current study, the last assessment of sexual function and depression outcomes was at 6 months postoperatively. Other authors also considered this period appropriate to detect differences in quality of life, self-esteem, functional capacity, and cosmetic outcomes after breast reduction.5–7,27 Our results demonstrate improvements in the sexual function of patients undergoing reduction mammaplasty at 3 and 6 months postoperatively, corroborating the results of a previous study.12 Some studies reported that, with an FSFI total score cutoff of 26.55 for the population of origin of the instrument, it is possible to discriminate between people with higher and lower risk for sexual dysfunction; values less than or equal to this point indicate sexual dysfunction.20,26 With the use of this cutoff value, there were fewer patients with sexual dysfunction in the group undergoing reduction mammaplasty at both 3 and 6 months postoperatively, confirming the positive impact of reduction mammaplasty on sexual function and quality of life in these patients. It should be noted that prospective studies evaluating depression in patients who underwent breast reduction are scarce.8,10,15,16 Studies on psychological changes after reduction mammaplasty have used various instruments to assess depression; the most commonly used is the Hospital Anxiety and Depression Scale.12,15,16 Only 1 study in the literature assessed depression in women with breast hypertrophy using the same instrument as that used in the present study and found that breast hypertrophy negatively affects the physical and psychological aspects of women.21 The well-standardized and widely used BDI has not been previously used in patients undergoing reduction mammaplasty. Two other studies used Raitasalo's modified version of the short form of the BDI.8,10 Therefore, we decided to use the BDI in the present study. Our results are similar to those of previous studies showing an association between breast hypertrophy and depressive symptoms and showing that women with breast hypertrophy have a higher rate of depressive symptoms than women who underwent reduction mammaplasty.8,10,15,16 Saariniemi et al8 reported that dissatisfaction with the outcome of surgery is related to anxiety and depression and that satisfaction with the operation is correlated with good preoperative information and a good relationship with the surgeon. Unfortunately, no instrument assessing patient satisfaction with the outcome of the surgery was used in the present study, making it impossible to confirm these associations. Souza Faria et al16 report that most patients are not clinically depressed before reduction mammaplasty and suggest that eventual mental disorders presented by women before surgery could be a direct result of their dissatisfaction with their breasts; such disturbances improved or were nonexistent after reduction mammaplasty. The present results corroborate these previous results. In general, reduction mammaplasty has been proven to effectively improve various aspects of the quality of life of patients, demonstrating that it provides not only esthetic benefits but also improvements in and relief from psychological symptoms due to mammary alteration.6,9
CONCLUSIONS In the current study, reduction mammaplasty improved patients' sexual function 3 and 6 months postoperatively and also improved depression levels at the sixth postoperative month. Thus, our results confirm the positive impact of reduction mammaplasty on the sexual function and depression levels of patients. This positive impact should be taken into account not only by the patients but also by managers
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and health care providers during the decision-making process regarding reduction mammaplasty. REFERENCES 1. Mello AA, Domingos NA, Miyazaki MC. Improvement in quality of life and selfesteem after breast reduction surgery. Aesthic Plast Surg. 2010;34:59–64. 2. Singh KA, Losken A. Additional benefits of reduction mammoplasty: a systematic review of the literature. Plast Reconstr Surg. 2012;129:562–570. 3. Singh KA, Pinell XA, Losken A. Is reduction mammaplasty a stimulus for weight loss and improved quality of life? Ann Plast Surg. 2010;64:585–587. 4. Kuzbari R, Schlenz I. Reduction mammaplasty and sensitivity of the nipple-areola complex: sensuality versus sexuality? Ann Plast Surg. 2007;58:3–11. 5. Freire MAMS, Sabino Neto M, Garcia EB, et al. Quality of life after reduction mammaplasty. Scand J Plast Reconstr Surg Hand Surg. 2004;38:335–339. 6. Freire M, Sabino Neto M, Garcia EB, et al. Functional capacity and postural pain outcomes after reduction mammaplasty. Plast Reconstr Surg. 2007;119:1149–1156. 7. Sabino Neto M, Demattê MF, Freire M, et al. Self-esteem and function capacity outcomes following reduction mammaplasty. Aesthet Surg J. 2008;4:417–420. 8. Saariniemi KM, Joukamaa M, Raitasalo R, et al. Breast reduction alleviates depression and anxiety and restores self-esteem: a prospective randomized clinical trial. Scand J Plast Reconstr Surg Hand Surg. 2009;43:320–324. 9. Saariniemi KM, Keranen UH, Salminen-Peltola PK, et al. Reduction mammaplasty is effective treatment according to two quality of life instruments: a prospective randomised clinical trial. J Plast Reconstr Aesthet Surg. 2008;61:1472–1478. 10. Saariniemi KM, Kuokkanen HO, Tukiainen EJ. The outcome of reduction mammaplasty remains stable at 2-5 years' follow-up: a prospective study. J Plast Reconstr Aesthet Surg. 2011;64:573–576. 11. Thiel RRC, Dambros M, Palmas PCR, et al. Translation in to Portuguese, crossnational adaptation and validation of the Female Sexual Function Index. Rev Bras Ginecol Obstet. 2008;30:504–510. 12. Cerovac S, Ali F, Blizard R, et al. Psychosexual function in womem who have undergone reduction mammaplasty. Plast Reconstr Surg. 2005;116:1306–1313. 13. Romeo M, Cuccia G, Zirilli A, et al. Reduction mammaplasty and related impact on psychosexual function. J Plast Reconstr Aesthet Surg. 2010;63:2112–2116. 14. Justo LP, Calil HM. Depression: the same affection for men and women? Rev Psiquiatr Clin. 2006;33:74–79. 15. Iwuagwu OC, Stanley PW, Platt AJ, et al. Effects of bilateral breast reduction on anxiety and depression: results of a prospective randomized trial. Scand J Plast Reconstr Surg Hand Surg. 2006;40:19–23. 16. Souza Faria F, Guthrie E, Bradbury E, et al. Psychosocial outcome and patient satisfaction following breast reduction surgery. Br J Plast Surg. 1999;52:448–452. 17. Sacchini V, Luini A, Tana S, et al. Quantitative and qualitative cosmetic evaluation after conservative treatment for breast cancer. Eur J Cancer. 1991;27:1395–1400. 18. Pacagnella RC, Vieira EM, Rodrigues OM Jr, et al. Cross-cultural adaptation of the Female Sexual Function Index. Cad Saude Publica. 2008;24:416–426. 19. Pacagnella RC, Martinez EZ, Vieira EM. Construct validity of a Portuguese version of the Female Sexual Female Index. Cad Saude Publica. 2009;25:2333–2344. 20. Wiegel M, Meston C, Rosen R. The Female Sexual Function Index (FSFI): crossvalidation and development of clinical cutoff scores. J Sex Marital Ther. 2005;31:1–20. 21. Gorestein C, Andrade L. Beck Depression Inventory: psychometric properties of the Portuguese version. Rev Bras Psiquiatr Clin. 1998;25:245–250. 22. Beck AT, Steer RA. Beck Depression Inventory: Manual. San Antonio, TX: Psychological Corp; 1993. 23. Valadares ALR, Pinto-Neto AM, Sousa MH, et al. Sociocultural adaptation of the Short Personal Experiences Questionnaire (SPEQ) in Brazil. Rev Bras Ginecol Obstet. 2010;32:72–76. 24. Saarwer DB, Lavery M, Spitzer JC. A review of the relationships between extreme obesity, quality of life, and sexual function. Obes Surg. 2012;22:668–676. 25. Pasqualotto EB, Pasqualotto FF, Sobreiro BP, et al. Female sexual dysfunction: the important points to remember. Clinics. 2005;60:51–60. 26. Furlanetto S, Rodrigues O Jr. Sexual satisfaction of the adult woman. Rev Bras Sex Hum. 1996;7:131–143. 27. Breiting LB, Henriksen TF, Kalialis LV, et al. A prospective study of short- and long-term cosmetic outcome after reduction mammaplasty from three different perspectives: the patient, a department surgeon, and an independent private practitioner in plastic surgery. Plast Reconstr Surg. 2012;130:273–281.
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