Assessing the Validity of the Schnur Sliding Scale in Young Women
Jonah I. Donnenfield, Laura C. Nuzzi, Catherine T. McNamara, Brian I. Labow
Department of Plastic and Oral Surgery, Boston Children's Hospital/Harvard Medical School, Cambridge, MA, United States.
The Schnur sliding scale (SSS) is used by many third-party payors to classify reduction mammaplasties as either cosmetic (below the SSS) or reconstructive (above the SSS). Although the SSS was developed using an adult cohort, it is applied to adolescent macromastia patients for whom there has been no validation of its medical utility. This study aims to compare the physical and psychosocial impact of reduction mammaplasty in adolescents above and below the SSS.
Health-related quality of life surveys were administered to patients, 12 to 21 y, undergoing reduction mammaplasty for macromastia. Surveys included Short Form-36v2 (SF-36), Rosenberg Self-Esteem Scale (RSES), and Breast-Related Symptoms Questionnaire (BRSQ). Age and BMI data were collected, and SSS values were determined for each patient. Paired t-tests compared preoperative and postoperative survey scores. Linear regression models, adjusted for BMI, evaluated the impact of undergoing resection greater than or less than the SSS on postoperative survey scores.
The average mass of resected tissue fell below the SSS for 39 patients and above the SSS for 255 patients. Groups featured no difference in mean age or BMI. Both groups had significant postoperative survey score improvements on the RSES, BRSQ, and in 7/8 SF-36 domains (P < .05, all).
Adolescents undergoing reduction mammaplasty above and below the SSS experienced comparable physical and psychosocial benefits. These findings underscore the need for third-party payers to broaden coverage for adolescent reduction mammaplasty, as the common reimbursement cutoff has no impact on overall postoperative benefit.
(A) Demographic characteristics of patients whose average mass of resected tissue did and did not meet the SSS value. (B) Within-subject comparisons of preoperative and most recent follow-up survey scores for patients above and below SSS.
| A | Below Schnur (n = 39) | Above Schnur (n = 255) | P | |
| Mean (SD) age, y | 18.2 (1.6) | 17.7 (1.9) | .06^a | |
| Mean (SD) BMI | 27.1 (4.0) | 27.4 (5.5) | .69^a | |
| Mean (SD) BMI percentile* | 83.3 (15.8) | 81.9 (18.4) | .63^a | |
| BMI Category, n (%) | .98^b | |||
| Healthy | 16 (41%) | 97 (38%) | ||
| Overweight | 13 (33%) | 92 (36%) | ||
| Obese | 10 (26%) | 66 (26%) | ||
| Race/Ethnicity, n (%) | .81^b | |||
| White | 27 (69%) | 147 (58%) | ||
| Black or African American | 2 (5%) | 26 (10%) | ||
| Hispanic | 2 (5%) | 17 (7%) | ||
| Other | 1 (3%) | 10 (4%) | ||
| Decline to answer/NA | 7 (18%) | 55 (21%) | ||
| B | Below Schnur Postoperative–Preoperative Difference,^c Mean (95% CI) | P^d | Above Schnur Postoperative–Preoperative Difference,^e Mean (95% CI) | P^d |
| SF-36 Domains | ||||
| Physical Functioning | 14.6 (8.3 to 20.9) | < .001 | 27.0 (23.8 to 30.2) | < .001 |
| Role Physical | 21.8 (13.8 to 29.8) | < .001 | 29.7 (26.1 to 33.2) | < .001 |
| Bodily Pain | 30.8 (22.3, 39.3) | < .001 | 32.5 (29.3 to 35.6) | < .001 |
| General Health | 3.6 (-1.7 to 8.8) | .18 | 4.9 (2.5 to 7.2) | < .001 |
| Vitality | 9.3 (4.8 to 13.9) | < .001 | 12.9 (10.3 to 15.5) | < .001 |
| Social Functioning | 23.7 (14.4 to 33.0) | < .001 | 21.2 (17.0 to 25.3) | < .001 |
| Role Emotional | 19.2 (9.9 to 28.6) | < .001 | 18.6 (14.5 to 22.8) | < .001 |
| Mental Health | 14.5 (8.5 to 20.5) | < .001 | 9.8 (6.9 to 12.6) | < .001 |
| RSES | 3.6 (1.8 to 5.5) | < .001 | 3.4 (3.0 to 4.7) | < .001 |
| EAT-26 | -2.6 (-7.6 to 2.4) | .30 | -2.8 (-1.4 to -4.1) | < .001 |
| BRSQ | 53.3 (46.5 to 60.2) | < .001 | 57.2 (54.8 to 59.6) | < .001 |
*Only applies to patients < 20 y of age (n = 34 and n = 223 for above groups, respectively).
a Two-sided P value for independent t-test.
b P value for Fisher exact test.
CI, confidence interval
c Mean difference between preoperative and postoperative survey scores for patients who underwent reduction mammaplasty and the average mass of resected tissue from breasts operated on was below the Schnur Sliding Scale threshold. A positive change in the mean indicates a score increase from preoperative to postoperative.
d P value for dependent t test for paired samples.
e Mean difference between preoperative and postoperative survey scores for patients who underwent reduction mammaplasty and the average mass of resected tissue from breasts operated on met or exceeded the Schnur Sliding Scale threshold. A positive change in the mean indicates a score increase from preoperative to postoperative.
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