Standardizing the complication rate after breast reduction using the Clavien-Dindo classification

Published:December 31, 2016DOI:


      Published complication rates for breast reduction surgery, also known as reduction mammaplasty, vary between 4% and 54%. This wide range of complication rates could be attributable to the lack of a standardized classification of complications in plastic surgery. The aim of this study was to analyze our single-center complication rates after reduction mammaplasty using the Clavien-Dindo classification.


      We performed a retrospective chart review studying 804 patients between the ages of 18 and 81 years old who underwent breast reduction between 2005 and 2015 at our institution. Patients with a history of breast cancer, a previous breast operation, who did not undergo bilateral reduction mammaplasty, or who required systemic immunodeficiency/immunosuppressive drugs were excluded from our analysis. Complications were classified according to the Clavien-Dindo classification from Grades I to V.


      A total of 486 patients met the inclusion criteria for the analysis. Patients had an age (mean ± standard deviation) of 39 ± 13 years and a body mass index of 26 ± 4 kg/m2. Median follow-up was 274 days (interquartile range: 90.5–378). The overall rate of complications of reduction mammaplasty was 63%, with the majority of those being Grades I (48%) and II (9%), comprising 92% of all the complications. Operative revisions were required in 6% (1% Grade IIIA and 5% Grade IIIB). There were no complications graded in categories IV and V.


      Although complications occurred in more than half of the cases, the majority did not require operative reintervention. The Clavien-Dindo classification can classify the severity of complications and serve as a benchmark to compare complication rates between different practices. We believe that grading of complications should distinguish between those that do and do not require operative reinterventions.
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        • Collins E.D.
        • Kerrigan C.L.
        • Kim M.
        • Lowery J.C.
        • Striplin D.T.
        • Cunningham B.
        • et al.
        The effectiveness of surgical and nonsurgical interventions in relieving the symptoms of macromastia.
        Plast Reconstr Surg. 2002; 109: 1556-1566
        • Cunningham B.L.
        • Gear A.J.L.
        • Kerrigan C.L.
        • Collins E.D.
        Analysis of breast reduction complications derived from the BRAVO study.
        Plast Reconstr Surg. 2005; 115: 1597-1604
        • Iwuagwu O.C.
        • Walker L.G.
        • Stanley P.W.
        • Hart N.B.
        • Platt A.J.
        • Drew P.J.
        Randomized clinical trial examining psychosocial and quality of life benefits of bilateral breast reduction surgery.
        Br J Surg. 2006; 93: 291-294
        • Gust M.J.
        • Smetona J.T.
        • Persing J.S.
        • Hanwright P.J.
        • Fine N.A.
        • Kim J.Y.S.
        The impact of body mass index on reduction mammaplasty.
        Aesthetic Surg J. 2013; 33: 1140-1147
        • Chun Y.S.
        • Schwartz M.A.
        • Gu X.
        • Lipsitz S.R.
        • Carty M.J.
        Body mass index as a predictor of postoperative complications in reduction mammaplasty.
        Plast Reconstr Surg. 2012; 129: 228e-233e
        • Bikhchandani J.
        • Varma S.K.
        • Henderson H.P.
        Is it justified to refuse breast reduction to smokers?.
        J Plast Reconstr Aesthetic Surg. 2007; 60: 1050-1054
        • Roehl K.
        • Craig E.S.
        • Gómez V.
        • Phillips L.G.
        Breast reduction: safe in the morbidly obese?.
        Plast Reconstr Surg. 2008; 122: 370-378
        • Setälä L.
        • Papp A.
        • Joukainen S.
        • Martikainen R.
        • Berg L.
        • Mustonen P.
        • et al.
        Obesity and complications in breast reduction surgery: are restrictions justified?.
        J Plast Reconstr Aesthetic Surg. 2009; 62: 195-199
        • Shah R.
        • Al-Ajam Y.
        • Stott D.
        • Kang N.
        Obesity in mammaplasty: a study of complications following breast reduction.
        J Plast Reconstr Aesthetic Surg. 2011; 64: 508-514
        • Clavien P.A.
        • Sanabria J.R.
        • Strasberg S.M.
        Proposed classification of complications of surgery with examples of utility in cholecystectomy.
        Surgery. 1992; 111: 518-526
        • Dindo D.
        • Demartines N.
        • Clavien P.A.
        Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey.
        Ann Surg. 2004; 240: 205-213
        • Clavien P.A.
        • Barkun J.
        • de Oliveira M.L.
        • Vauthey J.N.
        • Dindo D.
        • Schulick R.D.
        • et al.
        The Clavien-Dindo classification of surgical complications: five-year experience.
        Ann Surg. 2009; 250: 187-196
        • Antony A.K.
        • Yegiyants S.S.
        • Danielson K.K.
        • Wisel S.
        • Morris D.
        • Dolezal R.F.
        • et al.
        A matched cohort study of superomedial pedicle vertical scar breast reduction (100 breasts) and traditional inferior pedicle Wise-pattern reduction (100 breasts): an outcomes study over 3 years.
        Plast Reconstr Surg. 2013; 132: 1068-1076
        • Chang D.W.
        Maximizing outcomes in breast reduction surgery: a review of 518 consecutive patients.
        Breast Dis. 2006; 17: 295
        • Henry S.L.
        • Crawford J.L.
        • Puckett C.L.
        Risk factors and complications in reduction mammaplasty: novel associations and preoperative assessment.
        Plast Reconstr Surg. 2009; 124: 1040-1046
        • Spector J.A.
        • Singh S.P.
        • Karp N.S.
        Outcomes after breast reduction.
        Ann Plast Surg. 2008; 60: 505-509
        • Defazio M.V.
        • Fan K.L.
        • Avashia Y.J.
        • Tashiro J.
        • Ovadia S.
        • Husain T.
        • et al.
        Inferior pedicle breast reduction: a retrospective review of technical modifications influencing patient safety, operative efficiency, and postoperative outcomes.
        Am J Surg. 2012; 204: 7-14
        • Gamboa-Bobadilla G.M.
        • Killingsworth C.
        Large-volume reduction mammaplasty: the effect of body mass index on postoperative complications.
        Ann Plast Surg. 2007; 58: 246-249
        • O'Grady K.F.
        • Thoma A.
        • Dal Cin A.
        A comparison of complication rates in large and small inferior pedicle reduction mammaplasty.
        Plast Reconstr Surg. 2005; 115: 736-742
        • Pascone M.
        • Di Candia M.
        • Pascone C.
        The three dermoglandular flap support in reduction mammaplasty.
        Plast Reconstr Surg. 2012; 130: 1e-10e
        • Schumacher H.H.
        Breast reduction and smoking.
        Ann Plast Surg. 2005; 54: 117-119
        • Corion L.U.
        • Smeulders M.J.
        • van Zuijlen P.P.
        • van der Horst C.M.
        Draining after breast reduction: a randomised controlled inter-patient study.
        J Plast Reconstr Aesthetic Surg. 2009; 62: 865-868
        • Chan L.K.W.
        • Withey S.
        • Butler P.E.
        Smoking and wound healing problems in reduction mammaplasty: is the introduction of urine nicotine testing justified?.
        Ann Plast Surg. 2006; 56: 111-115
        • Platt A.J.
        • Mohan D.
        • Baguley P.
        The effect of body mass index and wound irrigation on outcome after bilateral breast reduction.
        Ann Plast Surg. 2003; 51: 552-555
        • Wagner D.S.
        • Alfonso D.R.
        The influence of obesity and volume of resection on success in reduction mammaplasty: an outcomes study.
        Plast Reconstr Surg. 2005; 115: 1034-1038
        • McCullagh P.
        Regression models for ordinal data.
        J R Stat Soc Series B Methodol. 1980; 42: 109-142
        • R Core Team
        R: a language and environment for statistical computing [Internet].
        The R Foundation, Vienna (Austria)2016 (Available from:)
        • Ozdalga E.
        • Ozdalga A.
        • Ahuja N.
        The smartphone in medicine: a review of current and potential use among physicians and students.
        J Med Internet Res. 2012; 14: e128
        • Chapman A.
        A history of surgical complications.
        in: Hakim N.S. Papalois V.E. Surgical complications. 1st ed. Imperial College Press, London2007: 1-40
        • Sokol D.K.
        • Wilson J.
        What is a surgical complication?.
        World J Surg. 2008; 32: 942-944
        • Yoon P.D.
        • Chalasani V.
        • Woo H.H.
        Use of Clavien-Dindo classification in reporting and grading complications after urological surgical procedures: analysis of 2010 to 2012.
        J Urol. 2013; 190: 1271-1274
        • Panhofer P.
        • Ferenc V.
        • Schütz M.
        • Gleiss A.
        • Dubsky P.
        • Jakesz R.
        • et al.
        Standardization of morbidity assessment in breast cancer surgery using the Clavien Dindo classification.
        Int J Surg. 2014; 12: 334-339
        • Mani M.
        • Wang T.
        • Harris P.
        • James S.
        Breast reconstruction with the deep inferior epigastric perforator flap is a reliable alternative in slim patients.
        Microsurgery. 2016; 36: 552-558
        • Pinsolle V.
        • Grinfeder C.
        • Mathoulin-Pelissier S.
        • Faucher A.
        Complications analysis of 266 immediate breast reconstructions.
        J Plast Reconstr Aesthetic Surg. 2006; 59: 1017-1024