The Influence of Reduction Mammaplasty on Dermato-Psychiatric Disorders Meme Küçültme Ameliyatlarının Dermato-Psikiyatrik Hastalıklar Üzerine Etkisi

Objective: Macromastia can cause psychiatric disorders, such as anxiety and depression, and decreases in self-esteem and self-confidence. These problems often externalize themselves on the skin, causing lesions characterized by various degrees of excoriations and lichenified plaques. Mammaplasty operations are very effective in the treatment of neurotic excoriations and similar skin lesions as well as any underlying psychiatric disorders. Materials and Methods: This study included 17 patients with macromastia and neurotic excoriation lesions who underwent psychiatric treatment for various reasons. Follow ups were performed using routine photographs used in breast surgeries. Results: During the postoperative follow ups, the excoriations for nearly every patient healed within 2 weeks. Some lesions healed with atrophic scars and some with permanent hyperpigmentation. Patients’ physical complaints, such as backache, shoulder ache and submammary pruritic dermatitis, were also observed to heal. In addition, the patients stated that they felt better psychologically, and most also reported stopping psychiatric treatment. Conclusion: The psychological problems caused by macromastia include neurotic excoriation and similar skin problems, and aesthetic reduction mammaplasty surgeries are very effective in the treatment of these lesions. Body image perception comprises an important part of self-respect and self-esteem, and psychological-status cosmetic surgery can be evaluated as an alternative to psychological treatment.


Introduction
Enhancements of a patient's physical, social and emotional conditions are parameters that determine success in the evaluation of cosmetic surgery results [1][2][3][4].Similar to obesity, there is a correlation between an increase in breast mass and depressive symptoms [5][6][7].Breasts are symbols of motherhood and femininity and have a special importance because they affect the psychology of women.In various studies, anxiety, depression and loss of self-esteem and selfrespect have been identified in 1/3 of patients applying for reduction mammaplasty [5,8].
The neuro-immuno-endocrine relationship between mental and affective disorders and skin diseases has been proven [9,10].Conflict in the limbic system expresses itself on the human skin and causes one or more red, swollen and lichenified plaques and lesions characterized by various degrees of excoriations [11].Neurotic excoriation, used synonymously with terms such as dermatillomania, compulsive skin picking and psychogenic excoriation, is frequently observed in women aged 20 to 40 [12].Such lesions are localized on areas of the body that can be reached by hand, such as the neck, shoulders, torso, back and extremities [12][13][14].
For dermatitis cases with underlying psychiatric disorders, the response to treatment is either very minimal or does not occur unless the underlying psychiatric disorder is resolved.Pruzinsky and Edgerton state that psychiatric disorders observed in the majority of cosmetic surgery patients will distinctively heal after aesthetic surgery [15].
In this study, neurotic excoriation lesions on various parts of macromastia patients who applied for reduction mammaplasty went into remission following surgical treatment.Our hypothesis is that reduction mammaplasty is effective in the treatment of both neurotic excoriations due to macromastia and lichen simplex circumscripta (neurodermatitis), which are observed during the later stages of this illness, and underlying psychiatric problems.

Materials and Methods
This study included 17 patients, aged 32 to 60 years (average 45.4 years), who applied to our clinic with macromastia from 2009-2012.The study was approved by the institutional ethics committee, and informed consent forms were obtained from all patients.Some of these patients were undergoing drug treatments for various psychiatric reasons, including anxiety, depression and obsessive-compulsive disorder.During the physical examinations of these macromastia patients, signs of excessive scratching on the breasts, torsos and shoulder extremities were observed in addition to excoriations and lesions that displayed pigmentation changes or that healed with crusts and scars (Figures 1a, 1b).Following a physical examination, these patients were diagnosed with neurotic excoriation and were followed up.The lesions were generally located in the mammary, periareolar and periumbilical regions.The lesions required an average of 3 weeks to heal (range 2-6 weeks).Follow ups were completed by taking pictures of the patients during breast surgery, after surgery and during routine control visits.

Results
The patients' postoperative follow ups were carried out as controls during the 1 st , 2 nd and 3 rd weeks and as monthly controls thereafter.The excoriations were observed to heal completely in nearly every patient within 2 weeks (Figures 2a,  2b).In 1 patient, the lesions decreased until the 3 rd postoperative week.However, the lesions did not completely heal, and new lesions were observed after the 3 rd week.In another patient, new lesions, albeit fewer in number compared to preoperation, were observed during the postoperative control in the 2 nd month (Figures 3a, 3b).Whereas the pre-operation lesions were located in the abdominal region and on the breasts, these new lesions were primarily located on the arms and shoulder caps.
For patients who were followed up for an average period of 5.5 months (2-11 months) during the postoperative period, some lesions were observed to heal with atrophic scars, whereas others healed with permanent hyperpigmentation.Eleven patients stated that they stopped using their medications during the postoperative period.A physical examination of the patients demonstrated that the neurotic excoriations had lessened dramatically or healed completely.This can be considered as solid proof of physical and mental healing in the patients.

Discussion
In this study, we observed the rapid healing of skin lesions following reduction mammaplasty for patients with neurotic excoriations.First, the patients' physical ailments, such as backache, shoulder ache and submammary pruritic dermatitis, subsided following reduction mammaplasty.In addition, patients had a more aesthetic and acceptable breast appearance.It is thought that some dermatologic and psychiatric sicknesses arise due to a common ectodermal root.Because of the dramatic healing of skin lesions following reduction mammaplasty in our study, we concluded that patients considered their breast size to be the basic problem and the source of all of their other problems.
Macromastia causes various psychological symptoms, such as anxiety and depression, which in turn cause a group of pruritic dermatoses, such as neurotic excoriation, neurodermatitis, psychogenic pruritus, lichen simplex chronicus and prurigo nodularis [16][17][18].Neurotic excoriation is used synonymously with dermatillomania, compulsive skin picking and psychogenic excoriation and is more frequently observed in females aged 20 to 40 years [12].Sufferers tend to continue scratching during attacks triggered by stress until pain and bleeding occurs [14,19].Neurotic excoriation is generally localized to the neck, shoulders, torso, back and extremities that the patient can reach by hand [12][13][14].The lesions become crusted, and a vicious cycle occurs with the picking of these crusts.The lesions rarely exceed 1 cm and heal with slight pigmentation changes or atrophic scars [14,19,20].The lesions in our patient groups were located on the shoulders and torso, and the repetitive lesions observed in 2 patients were located on other parts of the body, such as the neck and upper body.In addition, hyperpigmented areas and atrophic scars were commonly observed in our patients in accordance with the relevant literature.Following the operation, the healing process of the lesions required an average of 2 weeks.
Artifact dermatitis and parasitic delusion are also frequently observed with neurotic excoriation.In artifact dermatitis, the patient does not accept what he/she has performed, and the lesion is generally deep and large.Artifact dermatitis is comprised of geometric shapes and unnatural lesions made by patients using sharp or scorching items [19,20].With parasitic delusions, anamnesis is typical, and the patient states feeling small bugs crawling on his/her body [12].
Neurotic excoriation is generally observed in people with low self-esteem, sensitive people, introverts and perfectionists in addition to those who tend to blame themselves [12,19].Curing these skin lesions is not probable unless the real factor affecting the patient's psychology is resolved.A study by Collins et al. of patients with macromastia demonstrated that weight loss approaches, physiotherapy, special bras and support treatments did not provide permanent relief without surgery [1,3].Further, studies comparing aesthetic operations with psychiatric symptoms have indicated significant psychological progress following breast surgeries [21].
Body image perception comprises a significant portion of self-confidence and self-esteem, and psychological status may change dramatically after cosmetic surgery.Hence, cosmetic surgery can be evaluated as an alternative psychologi- A B cal treatment [21].Goin et al. [22] determined that 25% of the patients who underwent reduction mammaplasty in their study were in deep depression prior to the operation and that the depression regressed following the operation.Ohlsen et al. [23] reported that depression and low self-confidence and self-esteem improved following breast augmentation operations [24].
In conclusion, most patients who apply for breast surgeries may have underlying psychological disorders that manifest on the skin.Psychological disorders caused by macromastia can result in excoriation and similar skin problems.Aesthetic reduction mammaplasty is very effective in the treatment of these problems.Because various self-image problems result in psychological disorders and most psychological disorders manifest themselves on the skin, aesthetic surgery is generally curative for sicknesses arising from the image-psychology-skin interaction.

Conflict of interest statement:
The authors declare that they have no conflict of interest to the publication of this article.A B

70Figure 1 .
Figure 1.A) Preoperative anterior and lateral views of excoriations on breasts and shoulder B) Postoperative views of the lesions healing with pigmentation changes and scars.

FiratFigure 2 .Figure 3 .
Figure 2. A) Preoperative view of the neurotic excoriations at the breasts and periumblical region, B) View of the healed lesions postoperatively.