What preoperative evaluation is needed prior to breast reduction surgery?

Preoperative Evaluation for Breast Reduction Surgery

For breast reduction surgery, obtain a thorough history focusing on cardiovascular risk factors, bleeding disorders, and medications; perform a focused physical examination; and order preoperative mammography for women ≥40 years or those with breast cancer risk factors, while reserving laboratory testing for patients with specific comorbidities rather than ordering routine panels. 1, 2, 3

Essential History Components

Document the following specific elements:

• Cardiovascular risk factors including hypertension, diabetes, coronary disease, heart failure, and functional capacity (ability to climb ≥2 flights of stairs indicates ≥4 METs and generally allows proceeding without cardiac testing) 1, 2
• Bleeding history including personal or family history of bleeding disorders, easy bruising, or prolonged bleeding from minor procedures 1, 2
• Current medications particularly anticoagulants, antiplatelet agents, diuretics, ACE inhibitors, ARBs, NSAIDs, and any medications affecting coagulation or electrolytes 1, 2
• Tobacco use as this significantly impacts wound healing and complication rates in breast surgery 3, 4
• Family history of breast or ovarian cancer to guide mammography decisions 3
• Prior breast surgery or biopsies which increase the likelihood of occult pathology 3
• Comorbidities including renal disease, liver disease, hematologic disorders, and diabetes 1, 2

Physical Examination

Perform a focused examination assessing:

• Breast anatomy including size, symmetry, skin quality, nipple-areolar complex position, and presence of masses or skin changes 4
• Cardiovascular examination for signs of heart failure, arrhythmias, or valvular disease 1, 2
• Signs of anemia such as pallor or tachycardia 2

Imaging: Mammography

Preoperative mammography is indicated for:

• All women ≥40 years of age undergoing breast reduction, as 1.3% have high-risk lesions and 0.3% have occult malignancy in reduction specimens 3
• Women <40 years with risk factors including family history of breast cancer, prior breast biopsy, or prior breast surgery 3
• The rationale: Discovery of malignancy or high-risk lesions in the surgical specimen may preclude breast-conserving surgery options, making preoperative detection critical 3

Common pitfall: Many plastic surgeons do not routinely order mammography, but the discovery of invasive cancer in reduction specimens can significantly alter surgical management and oncologic outcomes 3

Laboratory Testing: Risk-Stratified Approach

The key principle: Order tests only when results would change perioperative management, not routinely for all patients. 1, 2

Complete Blood Count (CBC)

Obtain CBC for:

• Patients with history of anemia or recent blood loss 2
• Patients with diseases increasing anemia risk including liver disease or hematologic disorders 2
• When significant blood loss is anticipated (breast reduction typically involves moderate blood loss) 2

Electrolytes and Renal Function

Obtain electrolytes and creatinine for:

• Patients taking medications affecting electrolytes including diuretics, ACE inhibitors, ARBs, NSAIDs, or digoxin 1, 2
• Patients with hypertension, heart failure, chronic kidney disease, complicated diabetes, or liver disease 2

Do not order for healthy patients without these conditions 1, 2

Glucose Testing

Obtain random glucose for:

• Patients at high risk of undiagnosed diabetes (obesity, family history, metabolic syndrome) 1, 2
• Patients with known diabetes only if A1C results would change perioperative management 1, 2

The incidence of occult diabetes in presurgical populations is only 0.5%, making universal screening unjustified 2

Coagulation Studies

Obtain PT/aPTT/INR for:

• Patients with history of bleeding disorders or abnormal bleeding 1, 2
• Patients with liver disease or other conditions predisposing to coagulopathy 1, 2
• Patients taking anticoagulants 1, 2

Do not order for patients without these risk factors, as inherited coagulopathies have low prevalence and indiscriminate testing is not warranted 2

Urinalysis

Not indicated for breast reduction surgery unless the patient has urologic symptoms, as urinalysis is only recommended for urologic procedures or implantation of foreign material 1, 2

Electrocardiography (ECG)

Obtain preoperative ECG for:

• Patients with signs or symptoms of cardiovascular disease (chest pain, dyspnea, palpitations, syncope) 1, 2
• Patients undergoing intermediate-risk surgery with cardiovascular risk factors (coronary disease, structural heart disease, heart failure, cerebrovascular disease, diabetes, or renal impairment) - breast reduction falls into this category 1, 2
• Patients with poor functional capacity (<4 METs or unable to climb 2 flights of stairs) 2

Do not obtain for asymptomatic patients without cardiovascular risk factors undergoing low-risk procedures 1, 2

Chest Radiography

Not routinely indicated for asymptomatic patients 1, 2

Obtain only for:

• Patients with new or unstable cardiopulmonary signs or symptoms 1, 2
• Patients at risk of postoperative pulmonary complications if results would change management 1, 2

Special Consideration: Pregnancy Testing

Consider pregnancy testing for all women of childbearing age, as history and physical examination may be insufficient to identify early pregnancy 2

What NOT to Do

Avoid these common errors:

• Do not order routine test panels "just to be safe" or because "it's always been done" 2
• Do not use arbitrary age cutoffs as the sole indication for testing 2
• Do not order tests that will not alter perioperative care 2
• Do not skip mammography discussion in women ≥40 or those with risk factors, as this represents a critical opportunity to detect occult malignancy 3